Provider Demographics
NPI:1497053284
Name:TREASURED TEETH REUNION
Entity Type:Organization
Organization Name:TREASURED TEETH REUNION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DERREN
Authorized Official - Middle Name:E
Authorized Official - Last Name:TIPPETS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:303-853-9955
Mailing Address - Street 1:18335 E 103RD AVE UNIT 103
Mailing Address - Street 2:
Mailing Address - City:COMMERCE CITY
Mailing Address - State:CO
Mailing Address - Zip Code:80022-3103
Mailing Address - Country:US
Mailing Address - Phone:303-853-9955
Mailing Address - Fax:303-853-9954
Practice Address - Street 1:18335 E 103RD AVE UNIT 103
Practice Address - Street 2:
Practice Address - City:COMMERCE CITY
Practice Address - State:CO
Practice Address - Zip Code:80022-3103
Practice Address - Country:US
Practice Address - Phone:303-853-9955
Practice Address - Fax:303-853-9954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-03
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO95791223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO77383877Medicaid
CO10179054Medicaid