Provider Demographics
NPI:1053441956
Name:PRIMARY DENTAL LLC
Entity Type:Organization
Organization Name:PRIMARY DENTAL LLC
Other - Org Name:PRIMARY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHADWICK
Authorized Official - Middle Name:N
Authorized Official - Last Name:WILLIAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-433-1239
Mailing Address - Street 1:5801 W. 44TH AVE.
Mailing Address - Street 2:UNIT C
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80212
Mailing Address - Country:US
Mailing Address - Phone:303-433-1239
Mailing Address - Fax:303-455-5317
Practice Address - Street 1:5801 W. 44TH AVE
Practice Address - Street 2:UNIT C
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80212
Practice Address - Country:US
Practice Address - Phone:303-433-1239
Practice Address - Fax:303-455-5317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO68728816Medicaid