Provider Demographics
NPI:1396382727
Name:CRAIG KIDZDENTIST PLLC
Entity Type:Organization
Organization Name:CRAIG KIDZDENTIST PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KOLBY
Authorized Official - Middle Name:
Authorized Official - Last Name:LANCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-790-4170
Mailing Address - Street 1:1111 W VICTORY WAY
Mailing Address - Street 2:
Mailing Address - City:CRAIG
Mailing Address - State:CO
Mailing Address - Zip Code:81625
Mailing Address - Country:US
Mailing Address - Phone:435-790-4170
Mailing Address - Fax:
Practice Address - Street 1:1111 W VICTORY WAY
Practice Address - Street 2:
Practice Address - City:CRAIG
Practice Address - State:CO
Practice Address - Zip Code:81625
Practice Address - Country:US
Practice Address - Phone:435-790-4170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty