Provider Demographics
NPI:1124409552
Name:MODERN DENTAL PROFESIONALS CO PC
Entity Type:Organization
Organization Name:MODERN DENTAL PROFESIONALS CO PC
Other - Org Name:BRIGHTN NOW DENTAL - CASTLE ROCK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PC OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:MELLOR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-209-2250
Mailing Address - Street 1:PO BOX 25153
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92799-5153
Mailing Address - Country:US
Mailing Address - Phone:714-578-6358
Mailing Address - Fax:949-242-2631
Practice Address - Street 1:188 FOUNDERS PKWY # A
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-7528
Practice Address - Country:US
Practice Address - Phone:303-688-0252
Practice Address - Fax:303-660-9872
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MODERN DENTAL PROFESIONALS CO PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1057341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty