Provider Demographics
NPI:1265851042
Name:1075 S. PEORIA LLC
Entity Type:Organization
Organization Name:1075 S. PEORIA LLC
Other - Org Name:1 DAY DENTURES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SEUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-577-0377
Mailing Address - Street 1:1075 S PEORIA ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80012-3413
Mailing Address - Country:US
Mailing Address - Phone:303-341-4878
Mailing Address - Fax:
Practice Address - Street 1:1075 S PEORIA ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-3413
Practice Address - Country:US
Practice Address - Phone:303-341-4878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL ASSOCIATES OF AURORA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-09
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9056122300000X
CO7478122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO78931541Medicaid
CO96928832Medicaid