Provider Demographics
NPI:1154657294
Name:JOSEPH J. WIDDISON, DMD, PC
Entity Type:Organization
Organization Name:JOSEPH J. WIDDISON, DMD, PC
Other - Org Name:LAKEVIEW DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-371-2309
Mailing Address - Street 1:2502 ABARR DR
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-3156
Mailing Address - Country:US
Mailing Address - Phone:970-669-1444
Mailing Address - Fax:
Practice Address - Street 1:2502 ABARR DR
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-3156
Practice Address - Country:US
Practice Address - Phone:970-669-1444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-24
Last Update Date:2009-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9379261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental