1366896318 NPI number — PDC LOS NINOS LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366896318 NPI number — PDC LOS NINOS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PDC LOS NINOS LLC
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:
6
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:
1366896318
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2476 N UNIVERSITY PKWY STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROVO
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84604-3869
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-305-3460
Provider Business Mailing Address Fax Number:
801-692-9083

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1250 S SHERIDAN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENVER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80232-8022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-777-5437
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/15/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SKINNER
Authorized Official First Name:
KENDALL
Authorized Official Middle Name:
BRENT
Authorized Official Title or Position:
GENERAL DENTIST
Authorized Official Telephone Number:
303-777-5437

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  2924138903 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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