=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972033280
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THORNTON VALLEY DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16683 WASHINGTON ST BLDG 5
-----------------------------------------------------
City | THORNTON
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80023-8970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-450-3165
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16683 WASHINGTON ST BLDG 5
-----------------------------------------------------
City | THORNTON
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80023-8970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-450-3165
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | EVAN TYLER CETTIE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 832-470-6344
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 00202110
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------