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General NPI Number Information
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NPI Number | 1891749040
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Entity Type | Organization
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Legal Business Name | IMPLANT AND GENERAL DENTISTRY OF NORTHERN COLORADO
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Dates
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Enumeration Date | 05/20/2006
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Last Update Date | 05/17/2012
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Provider Practice Location Address
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Address Line | 2975 GINNALA DR STE 100
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City | LOVELAND
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State | CO
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Zip | 80538-3300
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Country | US
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Telephone | 970-663-1000
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Fax | 970-663-0615
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Provider Business Mailing Address
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Address Line | 2975 GINNALA DR STE 100
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City | LOVELAND
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State | CO
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Zip | 80538-3300
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Country | US
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Telephone | 970-663-1000
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Fax | 970-663-0615
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Authorized Official
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Title or Position | DENTIST
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Name | DR. THEODORE EUGENE MIODUSKI JR.
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Credential | D.D.S.
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Telephone | 970-663-1000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | CO8285
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | CO105715
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License Number State | CO
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