Provider Demographics
NPI:1114166865
Name:PEDO TWO, PROF. LLC
Entity Type:Organization
Organization Name:PEDO TWO, PROF. LLC
Other - Org Name:COMFORT DENTAL KIDS - LAKEWOOD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:COLTON
Authorized Official - Middle Name:
Authorized Official - Last Name:FLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:720-277-5930
Mailing Address - Street 1:6870 S UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80122-1515
Mailing Address - Country:US
Mailing Address - Phone:720-512-5879
Mailing Address - Fax:720-241-7811
Practice Address - Street 1:7475 W COLFAX AVE STE 103
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80214-5425
Practice Address - Country:US
Practice Address - Phone:720-512-2879
Practice Address - Fax:720-241-7811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-19
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10630122300000X, 1223P0221X
1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01928376Medicaid