MEDICARE: DENTAL MANAGEMENT GROUP LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	6616	CO

General Provider Information

NPI Number	:	1003170101
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL MANAGEMENT GROUP LLC

Provider Business Mailing Address
First Line	:	11246 E MISSISSIPPI AVE
Second Line	:
City	:	AURORA
State	:	CO
Zip	:	80012-3202
Country	:	US
Telephone Number	:	303-394-0231
Fax Number	:	303-329-4622

Provider Business Practice Location Address
First Line	:	3216 HIGH ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80205-4062
Country	:	US
Telephone Number	:	303-394-0231
Fax Number	:	303-329-4622

Authorized Official
Title or Position	:	ORAL SURGEON
Name	:	DR. ASHRAF SEDHOM
Credential	:
Telephone Number	:	303-394-0231

Provider Enumeration Date	:	07/03/2012
Last Update Date	:	07/03/2012

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