MEDICARE: GROUP PLATINE PROFESSIONAL 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	1223G0001X	General Practice Dentistry	6509	CO

General Provider Information

NPI Number	:	1326307521
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GROUP PLATINE PROFESSIONAL LLC

Provider Business Mailing Address
First Line	:	1818 MOUNTAIN VIEW AVE
Second Line	:
City	:	LONGMONT
State	:	CO
Zip	:	80501-3253
Country	:	US
Telephone Number	:	303-651-3733
Fax Number	:

Provider Business Practice Location Address
First Line	:	1818 MOUNTAIN VIEW AVE
Second Line	:
City	:	LONGMONT
State	:	CO
Zip	:	80501-3253
Country	:	US
Telephone Number	:	303-651-3733
Fax Number	:

Authorized Official
Title or Position	:	DDS/OWNER
Name	:	DR. RICHARD ABRAMS
Credential	:
Telephone Number	:	303-651-3733

Provider Enumeration Date	:	05/08/2012
Last Update Date	:	05/08/2012

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