1366896318 NPI number — PDC LOS NINOS LLC

Table of content: (NPI 1366896318)

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)