Provider Demographics
NPI:1164824769
Name:COLORADO ORTHODONTICS PROFESSIONAL, LLC
Entity Type:Organization
Organization Name:COLORADO ORTHODONTICS PROFESSIONAL, LLC
Other - Org Name:COLORADO ORTHODONTICS GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMERSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-943-2152
Mailing Address - Street 1:9227 E LINCOLN AVE
Mailing Address - Street 2:STE #800
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-5506
Mailing Address - Country:US
Mailing Address - Phone:720-943-2152
Mailing Address - Fax:
Practice Address - Street 1:9227 E LINCOLN AVE
Practice Address - Street 2:STE #800
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-5506
Practice Address - Country:US
Practice Address - Phone:720-943-2152
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO43971223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO4397OtherSTATE OF COLORADO