=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417366790
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRONT RANGE SMILES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2014
-----------------------------------------------------
Last Update Date | 09/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8870 N SUNDOWN TRL
-----------------------------------------------------
City | PARKER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-666-1162
-----------------------------------------------------
Fax | 720-222-5169
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11223 JANSEN ST.
-----------------------------------------------------
City | PARKER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-666-1162
-----------------------------------------------------
Fax | 720-222-5169
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, DOCTOR
-----------------------------------------------------
Name | DR. NATHANIEL CONRAD CEJKA
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 720-666-1162
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 10762
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------