MEDICARE: MODERN DENTAL PROFESSIONALS COLORADO PC

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	105731	CO

General Provider Information

NPI Number	:	1083095194
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN DENTAL PROFESSIONALS COLORADO PC

Provider Business Mailing Address
First Line	:	PO BOX 25153
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92799-5153
Country	:	US
Telephone Number	:	714-578-6358
Fax Number	:	949-242-2631

Provider Business Practice Location Address
First Line	:	7136 N ACADEMY BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-3185
Country	:	US
Telephone Number	:	719-452-4120
Fax Number	:	719-266-0108

Authorized Official
Title or Position	:	PC OWNER
Name	:	DR. CRAIG A MELLOR
Credential	:	DDS
Telephone Number	:	303-209-2250

Provider Enumeration Date	:	06/15/2015
Last Update Date	:	06/15/2015

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