Provider Demographics
NPI:1275924425
Name:PEDO LAKEWOOD LLC
Entity Type:Organization
Organization Name:PEDO LAKEWOOD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER OF PEDO LAKEWOOD LLC
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:CATMULL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-885-0635
Mailing Address - Street 1:9990 W 26TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80215-1581
Mailing Address - Country:US
Mailing Address - Phone:303-202-0880
Mailing Address - Fax:303-202-0882
Practice Address - Street 1:9990 W 26TH AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80215-1581
Practice Address - Country:US
Practice Address - Phone:303-202-0880
Practice Address - Fax:303-202-0882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-10
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00202066122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty