Provider Demographics
NPI:1124560669
Name:KIDS TOOTH DOC
Entity Type:Organization
Organization Name:KIDS TOOTH DOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-974-5868
Mailing Address - Street 1:5168 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113-6706
Mailing Address - Country:US
Mailing Address - Phone:303-974-5868
Mailing Address - Fax:
Practice Address - Street 1:9358 DORCHESTER ST
Practice Address - Street 2:SUITE 106
Practice Address - City:HIGHLANDS RANCH
Practice Address - State:CO
Practice Address - Zip Code:80129-2511
Practice Address - Country:US
Practice Address - Phone:303-974-5868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty