MEDICARE: RIVER NORTH DENTISTRY AND ORTHODONTICS PLLC

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	1223G0001X	General Practice Dentistry	203666	CO

General Provider Information

NPI Number	:	1073009049
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVER NORTH DENTISTRY AND ORTHODONTICS PLLC

Provider Business Mailing Address
First Line	:	2403 LACY LN
Second Line	:
City	:	CARROLLTON
State	:	TX
Zip	:	75006-6514
Country	:	US
Telephone Number	:	972-869-3789
Fax Number	:

Provider Business Practice Location Address
First Line	:	2656 WALNUT ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80205-2231
Country	:	US
Telephone Number	:	720-634-4040
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF CREDENTIALING
Name	:	FAITH GASKINS
Credential	:
Telephone Number	:	972-869-3789

Provider Enumeration Date	:	07/02/2018
Last Update Date	:	07/02/2018

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