MEDICARE: GREEN GABLES DENTAL 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	122300000X	Dentist	00202170	CO
2	1223D0004X	Dental Anesthesiology	02786101	CO
3	1223D0004X	Dental Anesthesiology	00202170	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508376906
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREEN GABLES DENTAL LLC

Provider Business Mailing Address
First Line	:	7586 W JEWELL AVE # 2-303
Second Line	:
City	:	LAKEWOOD
State	:	CO
Zip	:	80232-6890
Country	:	US
Telephone Number	:	720-442-8256
Fax Number	:	720-442-8246

Provider Business Practice Location Address
First Line	:	7586 W JEWELL AVE # 2-303
Second Line	:
City	:	LAKEWOOD
State	:	CO
Zip	:	80232-6890
Country	:	US
Telephone Number	:	720-442-8256
Fax Number	:	720-442-8246

Authorized Official
Title or Position	:	OWNER
Name	:	MICHAEL RIGGS
Credential	:
Telephone Number	:	720-442-8256

Provider Enumeration Date	:	10/11/2017
Last Update Date	:	11/22/2017

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Directions to “GREEN GABLES DENTAL LLC ” Practice Location

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