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General NPI Number Information
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NPI Number | 1720214638
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Entity Type | Organization
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Legal Business Name | PEDIATRIC DENTAL GROUP OF LAKEWOOD
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Dates
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Enumeration Date | 06/05/2009
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Last Update Date | 06/22/2020
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Provider Practice Location Address
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Address Line | 3333 S WADSWORTH BLVD UNIT B104
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City | LAKEWOOD
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State | CO
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Zip | 80227-5120
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Country | US
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Telephone | 303-984-9700
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Fax | 303-985-2490
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Provider Business Mailing Address
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Address Line | 3333 S WADSWORTH BLVD UNIT B102B104
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City | LAKEWOOD
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State | CO
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Zip | 80227-5122
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Country | US
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Telephone | 303-984-9700
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Fax | 303-985-2490
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | NICOLE E HARTSHORN
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Credential |
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Telephone | 720-338-9778
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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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 | 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 #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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