Provider Demographics
NPI:1003078742
Name:INNER CITY HEALTH CENTER
Entity Type:Organization
Organization Name:INNER CITY HEALTH CENTER
Other - Org Name:NEW HOPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTAL PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLAGRANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-296-4873
Mailing Address - Street 1:6301 W 38TH AVE
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-5057
Mailing Address - Country:US
Mailing Address - Phone:303-940-9118
Mailing Address - Fax:
Practice Address - Street 1:6301 W 38TH AVE
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-5057
Practice Address - Country:US
Practice Address - Phone:303-940-9118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-25
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO14003031Medicaid