Provider Demographics
NPI:1225562960
Name:KIT W HADDOW, DDS
Entity Type:Organization
Organization Name:KIT W HADDOW, DDS
Other - Org Name:KIT W HADDOW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KIT
Authorized Official - Middle Name:W
Authorized Official - Last Name:HADDOW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-245-2990
Mailing Address - Street 1:1910 N 12TH ST STE C
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-2934
Mailing Address - Country:US
Mailing Address - Phone:970-245-2990
Mailing Address - Fax:970-242-7924
Practice Address - Street 1:1910 N 12TH ST STE C
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-2934
Practice Address - Country:US
Practice Address - Phone:970-245-2990
Practice Address - Fax:970-242-7924
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KIT W HADDO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO104969122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02049690Medicaid