MEDICARE: MISSISSIPPI DENTAL GROUP P.C.

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	6097	CO

General Provider Information

NPI Number	:	1194846667
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSISSIPPI DENTAL GROUP P.C.

Provider Business Mailing Address
First Line	:	11175 E MISSISSIPPI AVE
Second Line	:	SUITE 110
City	:	AURORA
State	:	CO
Zip	:	80012-3137
Country	:	US
Telephone Number	:	303-343-9313
Fax Number	:	303-343-9537

Provider Business Practice Location Address
First Line	:	11175 E MISSISSIPPI AVE
Second Line	:	SUITE 110
City	:	AURORA
State	:	CO
Zip	:	80012-3137
Country	:	US
Telephone Number	:	303-343-9313
Fax Number	:	303-343-9537

Authorized Official
Title or Position	:	CREDENTIALING
Name	:	LAURIE SUMMERS
Credential	:
Telephone Number	:	303-285-6098

Provider Enumeration Date	:	04/03/2007
Last Update Date	:	08/22/2020

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