1043747900 NPI number — PEDIATRIC DENTAL GROUP OF WHEAT RIDGE

Table of content: (NPI 1043747900)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043747900 NPI number — PEDIATRIC DENTAL GROUP OF WHEAT RIDGE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC DENTAL GROUP OF WHEAT RIDGE
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:
1043747900
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/22/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3555 LUTHERAN PKWY
Provider Second Line Business Mailing Address:
SUITE 310
Provider Business Mailing Address City Name:
WHEAT RIDGE
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80033-6021
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3555 LUTHERAN PKWY
Provider Second Line Business Practice Location Address:
SUITE 310
Provider Business Practice Location Address City Name:
WHEAT RIDGE
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80033-6021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-467-8888
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/22/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BARDEN
Authorized Official First Name:
KRISTEN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
303-421-5437

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  8332 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X , with the licence number: 651 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X , with the licence number: 10389 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223X0400X , with the licence number: 104994 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223X0400X , with the licence number: 104928 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X , with the licence number: 7843 , 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)

  • Identifier: 38371847 , 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: 81227078 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 56483546 , 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: 64351084 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".