Provider Demographics
NPI:1225485873
Name:DENTISTRY 360
Entity Type:Organization
Organization Name:DENTISTRY 360
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SEMIRAMIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:CONDOIANIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:720-596-4760
Mailing Address - Street 1:5140 W DARTMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80236-2007
Mailing Address - Country:US
Mailing Address - Phone:720-596-4760
Mailing Address - Fax:720-596-4943
Practice Address - Street 1:5140 W DARTMOUTH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80236-2007
Practice Address - Country:US
Practice Address - Phone:720-596-4760
Practice Address - Fax:720-596-4943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO000102761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO58206051Medicaid