=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528540853
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALLIANCE DENTAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2018
-----------------------------------------------------
Last Update Date | 09/04/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12253 E 104TH PL UNIT 105
-----------------------------------------------------
City | COMMERCE CITY
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80022-2096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-853-8000
-----------------------------------------------------
Fax | 303-288-2219
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12253 E 104TH PL UNIT 105
-----------------------------------------------------
City | COMMERCE CITY
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80022-2096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-853-8000
-----------------------------------------------------
Fax | 303-288-2219
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER/MANAGER
-----------------------------------------------------
Name | JENNIE MACUMBER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 303-829-9243
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | DH.000903823
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DEN00202825
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------