Provider Demographics
NPI:1376142000
Name:PROFESSIONAL DENTAL CARE OF NORTHERN COLORADO II
Entity Type:Organization
Organization Name:PROFESSIONAL DENTAL CARE OF NORTHERN COLORADO II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARY
Authorized Official - Middle Name:
Authorized Official - Last Name:LACOUTURE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-521-5701
Mailing Address - Street 1:10233 S PARKER RD STE 107
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-9314
Mailing Address - Country:US
Mailing Address - Phone:303-887-8848
Mailing Address - Fax:
Practice Address - Street 1:112 DELMAR ST
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:CO
Practice Address - Zip Code:80751-4138
Practice Address - Country:US
Practice Address - Phone:970-522-5535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSUN HEALTH, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-10-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental