=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558953570
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHELLY JENA HONG
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2021
-----------------------------------------------------
Last Update Date | 08/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23963 E PROSPECT AVE UNIT E
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80016-5342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-400-9898
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10516 WESTCLIFF WAY
-----------------------------------------------------
City | HIGHLANDS RANCH
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80130-6917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | DEN.00204243
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------