MEDICARE: DR. JUSTIN KIMBALL LIDDLE DMD, CDT

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	1223P0700X	Prosthodontics	10142	CO

General Provider Information

NPI Number	:	1154634707
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUSTIN KIMBALL LIDDLE DMD, CDT

Provider Business Mailing Address
First Line	:	2001 S SHIELDS ST STE B1
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80526-1829
Country	:	US
Telephone Number	:	970-224-4358
Fax Number	:	970-224-4388

Provider Business Practice Location Address
First Line	:	2001 S SHIELDS ST STE B1
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80526-1829
Country	:	US
Telephone Number	:	970-224-4358
Fax Number	:	970-224-4388

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/23/2010
Last Update Date	:	07/23/2010

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