=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396033684
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTAL LIFELINE NETWORK COLORADO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2011
-----------------------------------------------------
Last Update Date | 07/20/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 15TH ST SUITE 100
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80202-6100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-534-5360
-----------------------------------------------------
Fax | 303-534-5290
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1800 15TH ST SUITE 100
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80202-6100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-534-5360
-----------------------------------------------------
Fax | 303-534-5290
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT AFFILIATE OPERATIONS
-----------------------------------------------------
Name | MS. MELISSA BOSWORTH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 720-287-6184
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251V00000X
-----------------------------------------------------
Taxonomy Name | Voluntary or Charitable Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------