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General NPI Number Information
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NPI Number | 1922247758
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Entity Type | Organization
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Legal Business Name | TREASURED TEETH PC
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Dates
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Enumeration Date | 02/18/2009
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Last Update Date | 02/18/2009
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Provider Practice Location Address
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Address Line | 100 TESSITORE CT UNIT C
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City | MONTROSE
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State | CO
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Zip | 81401-5689
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Country | US
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Telephone | 970-240-8694
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Fax | 970-240-8696
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Provider Business Mailing Address
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Address Line | 100 TESSITORE CT UNIT C
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City | MONTROSE
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State | CO
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Zip | 81401-5689
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Country | US
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Telephone | 970-240-8694
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Fax | 970-240-8696
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Authorized Official
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Title or Position | OWNER, PEDIATRIC DENTIST
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Name | DR. DERREN ELVIS TIPPETS
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Credential | DMD
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Telephone | 970-240-8694
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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 | 9579
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License Number State | CO
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