1568770162 NPI number — PERFECT TEETH-SPECIALTY CENTER PC

Table of content: (NPI 1568770162)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568770162 NPI number — PERFECT TEETH-SPECIALTY CENTER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERFECT TEETH-SPECIALTY CENTER PC
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:
1568770162
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7160 DALLAS PKWY STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLANO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75024-7111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-216-0661
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1699 S COLORADO BLVD
Provider Second Line Business Practice Location Address:
BUILDING A, SUITE J
Provider Business Practice Location Address City Name:
DENVER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80222-4036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-639-6000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/16/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
ANGEL
Authorized Official Middle Name:
K
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
254-216-0661

Provider Taxonomy Codes

  • Taxonomy code: 1223P0700X , with the licence number:  10196 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223S0112X , with the licence number: 10278 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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