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General NPI Number Information
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NPI Number | 1700645876
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Entity Type | Organization
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Legal Business Name | LANDMARK DENTAL STUDIO LLC
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Dates
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Enumeration Date | 03/18/2024
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Last Update Date | 03/18/2024
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Provider Practice Location Address
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Address Line | 5425 LANDMARK PL STE 307
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City | GREENWOOD VILLAGE
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State | CO
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Zip | 80111-1951
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Country | US
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Telephone | 303-773-8012
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Fax | 720-367-1011
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Provider Business Mailing Address
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Address Line | 5425 LANDMARK PL STE 307
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City | GREENWOOD VILLAGE
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State | CO
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Zip | 80111-1951
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Country | US
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Telephone | 303-773-8012
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Fax | 720-367-1011
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Authorized Official
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Title or Position | DENTIST/PARTNER
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Name | DR. RYAN SCOTT MICKLE
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Credential | DDS
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Telephone | 303-505-1015
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 126800000X
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Taxonomy Name | Dental Assistant
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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