MEDICARE: AMERICAN DENTAL EXCELLENCE

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	305R00000X	Preferred Provider Organization	7878	CO

General Provider Information

NPI Number	:	1164891545
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMERICAN DENTAL EXCELLENCE

Provider Business Mailing Address
First Line	:	905 W 124TH AVE., SUITE #130
Second Line	:
City	:	WESTMINSTER
State	:	CO
Zip	:	80234
Country	:	US
Telephone Number	:	303-920-4900
Fax Number	:	303-920-4823

Provider Business Practice Location Address
First Line	:	905 W 124TH AVE STE 130
Second Line	:
City	:	WESTMINSTER
State	:	CO
Zip	:	80234-1718
Country	:	US
Telephone Number	:	303-920-4900
Fax Number	:	303-920-4823

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. KENNETH JEFFERY POLKE
Credential	:	D.D.S
Telephone Number	:	303-920-4900

Provider Enumeration Date	:	09/16/2015
Last Update Date	:	09/16/2015

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Directions to “AMERICAN DENTAL EXCELLENCE ” Practice Location

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