Provider Demographics
NPI:1154486272
Name:NORTHEAST FAMILY DENTAL CLINIC
Entity Type:Organization
Organization Name:NORTHEAST FAMILY DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AARON
Authorized Official - Middle Name:C
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-774-6123
Mailing Address - Street 1:PO BOX 248
Mailing Address - Street 2:
Mailing Address - City:HAXTUN
Mailing Address - State:CO
Mailing Address - Zip Code:80731
Mailing Address - Country:US
Mailing Address - Phone:970-774-7999
Mailing Address - Fax:970-774-7997
Practice Address - Street 1:115 SOUTH COLORADO AVE
Practice Address - Street 2:
Practice Address - City:HASTUN
Practice Address - State:CO
Practice Address - Zip Code:80731
Practice Address - Country:US
Practice Address - Phone:970-774-7999
Practice Address - Fax:970-774-7997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO8895261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental