MEDICARE: CHOICE DENTAL CARE, 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	261QD0000X	Dental Clinic/Center	100950	CO

General Provider Information

NPI Number	:	1083932479
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHOICE DENTAL CARE, LLC

Provider Business Mailing Address
First Line	:	1040 E ELIZABETH ST
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-3951
Country	:	US
Telephone Number	:	970-224-4093
Fax Number	:	970-224-9246

Provider Business Practice Location Address
First Line	:	1040 E ELIZABETH ST
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-3951
Country	:	US
Telephone Number	:	970-224-4093
Fax Number	:	970-224-9246

Authorized Official
Title or Position	:	MEMBER
Name	:	THOMAS HARVEY
Credential	:	D.D.S.
Telephone Number	:	970-224-4093

Provider Enumeration Date	:	05/10/2010
Last Update Date	:	05/10/2010

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