Provider Demographics
NPI:1033650015
Name:FORT MOGAN DENTAL LLC
Entity Type:Organization
Organization Name:FORT MOGAN DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TACI
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-383-2083
Mailing Address - Street 1:617 WEST PLATTE AVE
Mailing Address - Street 2:AREA A
Mailing Address - City:FORT MORGAN
Mailing Address - State:CO
Mailing Address - Zip Code:80701-9306
Mailing Address - Country:US
Mailing Address - Phone:970-867-2128
Mailing Address - Fax:970-867-2128
Practice Address - Street 1:617 WEST PLATTE AVE
Practice Address - Street 2:AREA A
Practice Address - City:FORT MORGAN
Practice Address - State:CO
Practice Address - Zip Code:80701-9306
Practice Address - Country:US
Practice Address - Phone:970-867-4700
Practice Address - Fax:970-867-2128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-10
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00202298122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty