1720214638 NPI number — PEDIATRIC DENTAL GROUP OF LAKEWOOD

Table of content: (NPI 1720214638)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720214638 NPI number — PEDIATRIC DENTAL GROUP OF LAKEWOOD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC DENTAL GROUP OF LAKEWOOD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720214638
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3333 S WADSWORTH BLVD UNIT B102B104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKEWOOD
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80227-5122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-984-9700
Provider Business Mailing Address Fax Number:
303-985-2490

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3333 S WADSWORTH BLVD UNIT B104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80227-5120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-984-9700
Provider Business Practice Location Address Fax Number:
303-985-2490
Provider Enumeration Date:
06/05/2009

Additional Information

Authorized Official

Authorized Official Last Name:
HARTSHORN
Authorized Official First Name:
NICOLE
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
720-338-9778

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223X0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 44332866 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02006518 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02078434 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 38371847 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 83777709 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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