MEDICARE: COLORADO DENTAL PROFESSIONALS, 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

General Provider Information

NPI Number	:	1629571831
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLORADO DENTAL PROFESSIONALS, LLC

Provider Business Mailing Address
First Line	:	6691 W KEN CARYL AVE
Second Line	:
City	:	LITTLETON
State	:	CO
Zip	:	80128-5755
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6691 W KEN CARYL AVE
Second Line	:
City	:	LITTLETON
State	:	CO
Zip	:	80128-5755
Country	:	US
Telephone Number	:	303-979-4994
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING TEAM LEAD
Name	:	CASSANDRA PETERSEN
Credential	:
Telephone Number	:	217-540-8972

Provider Enumeration Date	:	03/14/2018
Last Update Date	:	03/14/2018

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Directions to “COLORADO DENTAL PROFESSIONALS, LLC ” Practice Location

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