Provider Demographics
NPI:1285021543
Name:FRONT RANGE PEDIATRIC DENTISTRY, PLLC
Entity Type:Organization
Organization Name:FRONT RANGE PEDIATRIC DENTISTRY, PLLC
Other - Org Name:COOL MOUNTAIN KIDS PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-550-1010
Mailing Address - Street 1:6160 TUTT BLVD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80923-3500
Mailing Address - Country:US
Mailing Address - Phone:719-550-1010
Mailing Address - Fax:719-550-1212
Practice Address - Street 1:6160 TUTT BLVD
Practice Address - Street 2:SUITE 140
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80923-3500
Practice Address - Country:US
Practice Address - Phone:719-550-1010
Practice Address - Fax:719-550-1212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-23
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN9841261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO64479871Medicaid