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General NPI Number Information
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NPI Number | 1467868596
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Entity Type | Organization
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Legal Business Name | ADVANCED DENTAL CENTER
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Dates
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Enumeration Date | 07/09/2014
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Last Update Date | 09/16/2015
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Provider Practice Location Address
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Address Line | 1557 W 84TH AVE UNIT 1
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City | FEDERAL HEIGHTS
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State | CO
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Zip | 80260-4780
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Country | US
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Telephone | 303-426-4860
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Fax | 303-426-1530
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Provider Business Mailing Address
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Address Line | 1557 W 84TH AVE UNIT 1
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City | FEDERAL HEIGHTS
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State | CO
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Zip | 80260-4780
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Country | US
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Telephone | 303-426-4860
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Fax | 303-426-1530
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Authorized Official
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Title or Position | PARTNER
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Name | DR. JASON RONALD VAN WAGENEN
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Credential |
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Telephone | 303-426-4860
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 8478
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License Number State | CO
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