Provider Demographics
NPI:1326553819
Name:COLORADO DENTAL PROFESSIONALS, LLC
Entity Type:Organization
Organization Name:COLORADO DENTAL PROFESSIONALS, LLC
Other - Org Name:MOUNTAIN RIDGE DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8426
Mailing Address - Street 1:2297 STATE HIGHWAY 7
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:CO
Mailing Address - Zip Code:80516-8009
Mailing Address - Country:US
Mailing Address - Phone:217-540-5100
Mailing Address - Fax:
Practice Address - Street 1:2297 STATE HIGHWAY 7
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:CO
Practice Address - Zip Code:80516-8009
Practice Address - Country:US
Practice Address - Phone:217-540-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLORADO DENTAL PROFESSIONALS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty