Provider Demographics
NPI:1497369185
Name:LUXURY TOOTH BOOTH INC.
Entity Type:Organization
Organization Name:LUXURY TOOTH BOOTH INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:J
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:RDH, BSDH
Authorized Official - Phone:720-427-7001
Mailing Address - Street 1:1190 EVERETT CT
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80215-4829
Mailing Address - Country:US
Mailing Address - Phone:720-427-7001
Mailing Address - Fax:
Practice Address - Street 1:1190 EVERETT CT
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80215-4829
Practice Address - Country:US
Practice Address - Phone:720-427-7001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO962028464Medicaid