MEDICARE: 5TH AVE SMILE 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	124Q00000X	Dental Hygienist	DH.002024345	CO

General Provider Information

NPI Number	:	1144742628
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	5TH AVE SMILE LLC

Provider Business Mailing Address
First Line	:	2044 CLINTON ST UNIT B
Second Line	:
City	:	AURORA
State	:	CO
Zip	:	80010-1003
Country	:	US
Telephone Number	:	303-360-7462
Fax Number	:	303-360-7475

Provider Business Practice Location Address
First Line	:	2044 CLINTON ST UNIT B
Second Line	:
City	:	AURORA
State	:	CO
Zip	:	80010-1003
Country	:	US
Telephone Number	:	303-360-7462
Fax Number	:	303-360-7475

Authorized Official
Title or Position	:	DENTAL HYGIENIST
Name	:	MR. JUSTICE OSEI TUTU
Credential	:
Telephone Number	:	303-360-7462

Provider Enumeration Date	:	07/17/2017
Last Update Date	:	07/21/2022

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