Provider Demographics
NPI:1346393956
Name:MOUNTAIN RANGE DENTISTRY
Entity Type:Organization
Organization Name:MOUNTAIN RANGE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:K
Authorized Official - Last Name:MIZOUE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-452-2221
Mailing Address - Street 1:1005 W 120TH AVE
Mailing Address - Street 2:SUITE 800
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80234-2714
Mailing Address - Country:US
Mailing Address - Phone:303-452-2221
Mailing Address - Fax:303-450-9954
Practice Address - Street 1:1005 W 120TH AVE
Practice Address - Street 2:SUITE 800
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80234-2714
Practice Address - Country:US
Practice Address - Phone:303-452-2221
Practice Address - Fax:303-450-9954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1053411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty