Provider Demographics
NPI:1316541733
Name:FUN AT THE DENTIST PROFESSIONAL LLC
Entity Type:Organization
Organization Name:FUN AT THE DENTIST PROFESSIONAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JEANETT
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-255-1111
Mailing Address - Street 1:2525 N 8TH ST STE 105
Mailing Address - Street 2:
Mailing Address - City:GRAND JCT
Mailing Address - State:CO
Mailing Address - Zip Code:81501-8808
Mailing Address - Country:US
Mailing Address - Phone:970-255-1111
Mailing Address - Fax:970-241-5555
Practice Address - Street 1:2525 N 8TH ST STE 105
Practice Address - Street 2:
Practice Address - City:GRAND JCT
Practice Address - State:CO
Practice Address - Zip Code:81501-8808
Practice Address - Country:US
Practice Address - Phone:970-255-1111
Practice Address - Fax:970-241-5555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO16037375Medicaid