MEDICARE: PEDIATRIC SEDATION DENTISTRY OF COLORADO 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	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1841040243
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC SEDATION DENTISTRY OF COLORADO PLLC

Provider Business Mailing Address
First Line	:	2755 ELIOT ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80211-4111
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4027 BOARDWALK DR
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-5938
Country	:	US
Telephone Number	:	720-828-2106
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MATTHEW LUCERO
Credential	:	DMD
Telephone Number	:	720-828-2106

Provider Enumeration Date	:	03/26/2024
Last Update Date	:	03/26/2024

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