Provider Demographics
NPI:1083113765
Name:MOUNTAIN VALLEY KIDS DENTAL, PLLC
Entity Type:Organization
Organization Name:MOUNTAIN VALLEY KIDS DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:D.
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:TOBLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-883-1748
Mailing Address - Street 1:PO BOX 805
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81402
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 EDWARDS VILLAGE BLVD., #D-202
Practice Address - Street 2:PO BOX 41
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632
Practice Address - Country:US
Practice Address - Phone:303-883-1748
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-07
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
122300000X, 1223G0001X
CO96911223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty