Provider Demographics
NPI:1205358017
Name:COLLEGE AVE MODERN DENTAL PRACTICE, LLC
Entity Type:Organization
Organization Name:COLLEGE AVE MODERN DENTAL PRACTICE, LLC
Other - Org Name:COLLEGE AVE MODERN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:FREDERICK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-233-8933
Mailing Address - Street 1:3617 S COLLEGE AVE UNIT B
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-3009
Mailing Address - Country:US
Mailing Address - Phone:970-233-8933
Mailing Address - Fax:888-790-7062
Practice Address - Street 1:3617 S COLLEGE AVE UNIT B
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-3009
Practice Address - Country:US
Practice Address - Phone:970-233-8933
Practice Address - Fax:888-790-7062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10115122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty