Provider Demographics
NPI:1093121667
Name:PATRA WATANA DMD PEDIATRIC DENTISTRY LLC
Entity Type:Organization
Organization Name:PATRA WATANA DMD PEDIATRIC DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WATANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-740-7088
Mailing Address - Street 1:8200 E BELLEVIEW AVE
Mailing Address - Street 2:SUITE #420E
Mailing Address - City:GREENWOOD VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:80111-2803
Mailing Address - Country:US
Mailing Address - Phone:303-740-7088
Mailing Address - Fax:
Practice Address - Street 1:8200 E. BELLEVIEW AVE.
Practice Address - Street 2:SUITE #420E
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111
Practice Address - Country:US
Practice Address - Phone:303-740-7088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-03
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO66141223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02123371Medicaid