Provider Demographics
NPI:1235499294
Name:DENTISTRY360
Entity Type:Organization
Organization Name:DENTISTRY360
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SEMI
Authorized Official - Middle Name:
Authorized Official - Last Name:CONDOIANIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:214-693-4022
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:2012-05-24
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10276261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO58206051Medicaid