Provider Demographics
NPI:1215179148
Name:CHILDREN'S DENTAL CENTER
Entity Type:Organization
Organization Name:CHILDREN'S DENTAL CENTER
Other - Org Name:JOHN R SEXTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-985-0918
Mailing Address - Street 1:2323 S WADSWORTH BLVD
Mailing Address - Street 2:SUITE # 104
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80227-3275
Mailing Address - Country:US
Mailing Address - Phone:303-985-0918
Mailing Address - Fax:303-985-2490
Practice Address - Street 1:2323 S WADSWORTH BLVD
Practice Address - Street 2:SUITE # 104
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80227-3275
Practice Address - Country:US
Practice Address - Phone:303-985-0918
Practice Address - Fax:303-985-2490
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S DENTAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-24
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1047081223P0221X
CO90601223P0221X
CO1058551223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04104709Medicaid