=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952809964
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LARIMER SQUARE PROFESSIONAL DENTAL GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2018
-----------------------------------------------------
Last Update Date | 01/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1512 LARIMER ST
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80202-1610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-617-8400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16981 E QUINCY AVE # D1-D3
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80015-2769
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-617-8400
-----------------------------------------------------
Fax | 303-617-3516
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER/OWNER
-----------------------------------------------------
Name | JAMES LIU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 303-862-0297
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------