Provider Demographics
NPI:1326307521
Name:GROUP PLATINE PROFESSIONAL LLC
Entity Type:Organization
Organization Name:GROUP PLATINE PROFESSIONAL LLC
Other - Org Name:RADIANCE DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DDS/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:ABRAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-651-3733
Mailing Address - Street 1:1818 MOUNTAIN VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3253
Mailing Address - Country:US
Mailing Address - Phone:303-651-3733
Mailing Address - Fax:
Practice Address - Street 1:1818 MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3253
Practice Address - Country:US
Practice Address - Phone:303-651-3733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-08
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO65091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty