MEDICARE: KIDS MILE HIGH PEDIATRIC DENTISTRY AND ORTHODONTICS, PLLC

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	8538	CO

General Provider Information

NPI Number	:	1306336318
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDS MILE HIGH PEDIATRIC DENTISTRY AND ORTHODONTICS, PLLC

Provider Business Mailing Address
First Line	:	1780 S BELLAIRE ST STE 345
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80222-4355
Country	:	US
Telephone Number	:	303-744-1701
Fax Number	:

Provider Business Practice Location Address
First Line	:	125 INVERNESS DR E STE 300
Second Line	:
City	:	ENGLEWOOD
State	:	CO
Zip	:	80112-5139
Country	:	US
Telephone Number	:	303-779-5306
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ORTHODONTIST
Name	:	DR. JUSTIN MICHAEL OWENS
Credential	:	DDS
Telephone Number	:	303-744-1701

Provider Enumeration Date	:	05/15/2018
Last Update Date	:	05/15/2018

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