Provider Demographics
NPI:1356496558
Name:BLUE MESA DENTISTRY AT THE CREST
Entity Type:Organization
Organization Name:BLUE MESA DENTISTRY AT THE CREST
Other - Org Name:DENTISTRY AT THE CREST
Other - Org Type:Other Name
Authorized Official - Title/Position:ASSOCIATE DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:M
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-768-8848
Mailing Address - Street 1:10047 PARK MEADOWS DR
Mailing Address - Street 2:#B
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124
Mailing Address - Country:US
Mailing Address - Phone:303-768-8848
Mailing Address - Fax:303-768-8858
Practice Address - Street 1:10047 PARK MEADOWS DR
Practice Address - Street 2:#B
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124
Practice Address - Country:US
Practice Address - Phone:303-768-8848
Practice Address - Fax:303-768-8858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO86961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty