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General NPI Number Information
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NPI Number | 1639561467
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Entity Type | Organization
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Legal Business Name | AJ CANON DENTAL
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Dates
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Enumeration Date | 03/03/2015
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Last Update Date | 03/03/2015
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Provider Practice Location Address
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Address Line | 1227 S 9TH ST
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City | CANON CITY
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State | CO
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Zip | 81212-4211
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Country | US
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Telephone | 719-285-4784
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Fax | 719-345-4120
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Provider Business Mailing Address
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Address Line | 1227 S 9TH ST
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City | CANON CITY
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State | CO
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Zip | 81212-4211
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Country | US
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Telephone | 719-285-4784
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Fax | 719-345-4120
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Authorized Official
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Title or Position | OWNER
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Name | DR. ALLEN JESSE LEE
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Credential | DMD
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Telephone | 650-722-0005
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 10543
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License Number State | CO
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