Provider Demographics
NPI:1235621822
Name:COLORADO DENTAL PROFESSIONALS, LLC
Entity Type:Organization
Organization Name:COLORADO DENTAL PROFESSIONALS, LLC
Other - Org Name:WATERPARK DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING TEAM LEAD
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8972
Mailing Address - Street 1:2530 S PARKER RD STE 202
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-1629
Mailing Address - Country:US
Mailing Address - Phone:303-750-2290
Mailing Address - Fax:
Practice Address - Street 1:2530 S PARKER RD STE 202
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-1629
Practice Address - Country:US
Practice Address - Phone:303-750-2290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLORADO DENTAL PROFESSIONALS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-31
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty