Provider Demographics
NPI:1215194543
Name:FORT LUPTON DENTAL GROUP P.C.
Entity Type:Organization
Organization Name:FORT LUPTON DENTAL GROUP P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:MARGARET
Authorized Official - Last Name:HOLLOMA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-857-4377
Mailing Address - Street 1:229 DENVER AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-1819
Mailing Address - Country:US
Mailing Address - Phone:303-857-4377
Mailing Address - Fax:
Practice Address - Street 1:229 DENVER AVE
Practice Address - Street 2:
Practice Address - City:FORT LUPTON
Practice Address - State:CO
Practice Address - Zip Code:80621-1819
Practice Address - Country:US
Practice Address - Phone:303-857-4377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COHD104267122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty