1689987083 NPI number — GARRY DEAN MILLARD DDS

Table of content: GARRY DEAN MILLARD DDS (NPI 1689987083)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689987083 NPI number — GARRY DEAN MILLARD DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLARD
Provider First Name:
GARRY
Provider Middle Name:
DEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

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:
1689987083
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/31/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1905 BLAKE AVE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
GLENWOOD SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81601-4288
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-945-2840
Provider Business Mailing Address Fax Number:
970-945-2893

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
195 W 14TH
Provider Second Line Business Practice Location Address:
BUILDING C
Provider Business Practice Location Address City Name:
RIFLE
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81650-4700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-945-2840
Provider Business Practice Location Address Fax Number:
970-945-2893
Provider Enumeration Date:
07/14/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  00010351 , 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: 57402086 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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