Provider Demographics
NPI:1043747900
Name:PEDIATRIC DENTAL GROUP OF WHEAT RIDGE
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL GROUP OF WHEAT RIDGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-421-5437
Mailing Address - Street 1:3555 LUTHERAN PKWY
Mailing Address - Street 2:SUITE 310
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-6021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3555 LUTHERAN PKWY
Practice Address - Street 2:SUITE 310
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-6021
Practice Address - Country:US
Practice Address - Phone:303-467-8888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC DENTAL GROUP OF COLORADO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-05-22
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO78431223P0221X
CO83321223P0221X
CO6511223P0221X
CO103891223P0221X
CO1049941223X0400X
CO1049281223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO38371847Medicaid
CO02078434Medicaid
CO81227078Medicaid
CO56483546Medicaid
CO02006518Medicaid
CO64351084Medicaid