Provider Demographics
NPI:1376733501
Name:AAA FAMILY DENTAL CENTER III PC
Entity Type:Organization
Organization Name:AAA FAMILY DENTAL CENTER III PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:LOSACCO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-569-3141
Mailing Address - Street 1:PO BOX 1022
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:CO
Mailing Address - Zip Code:80444-1022
Mailing Address - Country:US
Mailing Address - Phone:303-569-3141
Mailing Address - Fax:303-569-3041
Practice Address - Street 1:801 6TH ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:CO
Practice Address - Zip Code:80444-1022
Practice Address - Country:US
Practice Address - Phone:303-569-3141
Practice Address - Fax:303-569-3041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO105584122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04011847Medicaid