Provider Demographics
NPI:1346679321
Name:MOD LLC
Entity Type:Organization
Organization Name:MOD LLC
Other - Org Name:KIDSFIRST DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:LUKE
Authorized Official - Middle Name:
Authorized Official - Last Name:MILMONT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-772-1793
Mailing Address - Street 1:2121 MIDPOINT DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-4339
Mailing Address - Country:US
Mailing Address - Phone:970-484-5437
Mailing Address - Fax:970-484-5436
Practice Address - Street 1:2121 MIDPOINT DR
Practice Address - Street 2:SUITE 102
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-4339
Practice Address - Country:US
Practice Address - Phone:970-484-5437
Practice Address - Fax:970-484-5436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-11
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental