Provider Demographics
NPI:1225131154
Name:RIDGE STREET DENTAL
Entity Type:Organization
Organization Name:RIDGE STREET DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NEILL
Authorized Official - Middle Name:CURTIS
Authorized Official - Last Name:SLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-453-1996
Mailing Address - Street 1:PO BOX 5620
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80424-5620
Mailing Address - Country:US
Mailing Address - Phone:970-453-1996
Mailing Address - Fax:970-453-1171
Practice Address - Street 1:213 S. RIDGE ST
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:CO
Practice Address - Zip Code:80424
Practice Address - Country:US
Practice Address - Phone:970-453-1996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO55211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1223OtherGENERAL DENTIST