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General NPI Number Information
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NPI Number | 1922244193
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Entity Type | Organization
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Legal Business Name | MOUNTAIN DENTAL PC
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Dates
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Enumeration Date | 12/18/2008
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Last Update Date | 12/18/2008
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Provider Practice Location Address
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Address Line | 300 NICKEL ST STE 11
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City | BROOMFIELD
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State | CO
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Zip | 80020-2097
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Country | US
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Telephone | 303-635-1816
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Fax |
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Provider Business Mailing Address
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Address Line | 300 NICKEL ST STE 11
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City | BROOMFIELD
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State | CO
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Zip | 80020-2097
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Country | US
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Telephone | 303-635-1816
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Fax |
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Authorized Official
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Title or Position | PROFESSIONAL SERVICES
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Name | LORI PELKE
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Credential |
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Telephone | 715-926-5050
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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