Provider Demographics
NPI:1144742628
Name:5TH AVE SMILE LLC
Entity Type:Organization
Organization Name:5TH AVE SMILE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTAL HYGIENIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTICE
Authorized Official - Middle Name:
Authorized Official - Last Name:OSEI TUTU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-360-7462
Mailing Address - Street 1:2044 CLINTON ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80010-1003
Mailing Address - Country:US
Mailing Address - Phone:303-360-7462
Mailing Address - Fax:303-360-7475
Practice Address - Street 1:2044 CLINTON ST UNIT B
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80010-1003
Practice Address - Country:US
Practice Address - Phone:303-360-7462
Practice Address - Fax:303-360-7475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH.002024345124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty