1053497735 NPI number — MODERN DENTAL PROFESSIONALS COLORADO PC

Table of content: (NPI 1053497735)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053497735 NPI number — MODERN DENTAL PROFESSIONALS COLORADO PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MODERN DENTAL PROFESSIONALS COLORADO 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:
BRIGHT NOW DENTAL
Provider Other Organization Name Type Code:
3
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:
1053497735
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 SANDPOINTE AVE FL 8
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA ANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92707-5778
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-428-1300
Provider Business Mailing Address Fax Number:
714-428-1390

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1955 ARAPAHOE ST
Provider Second Line Business Practice Location Address:
SUITE #A
Provider Business Practice Location Address City Name:
DENVER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80202-1851
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-296-0888
Provider Business Practice Location Address Fax Number:
303-292-2634
Provider Enumeration Date:
10/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STIREWALT
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
714-428-1300

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  9133 , 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)





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