=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649988304
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE DENTAL GROUP LITTLETON INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2022
-----------------------------------------------------
Last Update Date | 10/04/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5125 S KIPLING PKWY STE 315
-----------------------------------------------------
City | LITTLETON
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80127-1710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-515-7095
-----------------------------------------------------
Fax | 720-343-5813
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5125 S KIPLING PKWY STE 315
-----------------------------------------------------
City | LITTLETON
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80127-1710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-515-7095
-----------------------------------------------------
Fax | 720-343-5813
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/DENTIST
-----------------------------------------------------
Name | DR. KYU JUNG
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 303-515-7095
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------