Provider Demographics
NPI:1477652378
Name:MAIN STREET FAMILY DENISTRY
Entity Type:Organization
Organization Name:MAIN STREET FAMILY DENISTRY
Other - Org Name:SMILE DESIGNERS FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:P
Authorized Official - Last Name:DRAKE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-678-7800
Mailing Address - Street 1:1246 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501
Mailing Address - Country:US
Mailing Address - Phone:303-678-7800
Mailing Address - Fax:303-678-5375
Practice Address - Street 1:1246 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501
Practice Address - Country:US
Practice Address - Phone:303-678-7800
Practice Address - Fax:303-678-5375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty