=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497174155
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVERWALK PERIODONTICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2014
-----------------------------------------------------
Last Update Date | 04/09/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 280 MAIN ST QUARTZ C-106
-----------------------------------------------------
City | EDWARDS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81632-8501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-766-6000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 280 MAIN ST QUARTZ C-106
-----------------------------------------------------
City | EDWARDS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81632-8501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-766-6000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | DR. JAMES E BEARD
-----------------------------------------------------
Credential | DMD, MS
-----------------------------------------------------
Telephone | 773-383-3878
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | DEN.00202129
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------