Provider Demographics
NPI:1417501180
Name:MY LOCAL COLORADO DENTAL PRACTICE, LLC
Entity Type:Organization
Organization Name:MY LOCAL COLORADO DENTAL PRACTICE, LLC
Other - Org Name:STANDLEY LAKE FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSTELAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-372-5605
Mailing Address - Street 1:8721 WADSWORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80003-0929
Mailing Address - Country:US
Mailing Address - Phone:720-605-4302
Mailing Address - Fax:
Practice Address - Street 1:8721 WADSWORTH BLVD
Practice Address - Street 2:
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80003-0929
Practice Address - Country:US
Practice Address - Phone:720-605-4302
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MY LOCAL COLORADO DENTAL PRACTICE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-07-30
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty