MEDICARE: MOD 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	261QD0000X	Dental Clinic/Center		CO

General Provider Information

NPI Number	:	1346679321
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOD LLC

Provider Business Mailing Address
First Line	:	2121 MIDPOINT DR
Second Line	:	SUITE 102
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-4339
Country	:	US
Telephone Number	:	970-484-5437
Fax Number	:	970-484-5436

Provider Business Practice Location Address
First Line	:	2121 MIDPOINT DR
Second Line	:	SUITE 102
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-4339
Country	:	US
Telephone Number	:	970-484-5437
Fax Number	:	970-484-5436

Authorized Official
Title or Position	:	PEDIATRIC DENTIST
Name	:	LUKE MILMONT
Credential	:
Telephone Number	:	307-772-1793

Provider Enumeration Date	:	11/11/2013
Last Update Date	:	12/01/2016

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Directions to “MOD LLC ” Practice Location

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