Provider Demographics
NPI:1346969730
Name:AURORA PEDO DENTAL, PLLC
Entity Type:Organization
Organization Name:AURORA PEDO DENTAL, PLLC
Other - Org Name:GRIN PEDIATRIC DENTISTRY & ORTHODONTICS OF AURORA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:COLTON
Authorized Official - Middle Name:
Authorized Official - Last Name:FLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:720-579-8855
Mailing Address - Street 1:6870 S UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80122-1515
Mailing Address - Country:US
Mailing Address - Phone:720-399-1227
Mailing Address - Fax:720-241-7811
Practice Address - Street 1:18801 E HAMPDEN AVE STE 178
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80013-3587
Practice Address - Country:US
Practice Address - Phone:720-277-5930
Practice Address - Fax:720-241-7811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-26
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01928376Medicaid
CO35759046Medicaid
CO44075871Medicaid
CO9000182876Medicaid