Provider Demographics
NPI:1497928527
Name:VILLAGE PARK DENTAL PC
Entity Type:Organization
Organization Name:VILLAGE PARK DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSTY
Authorized Official - Middle Name:KIP
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-364-6455
Mailing Address - Street 1:11275 E MISSISSIPPI AVE
Mailing Address - Street 2:2 SOUTH 3
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80012-3263
Mailing Address - Country:US
Mailing Address - Phone:303-364-6455
Mailing Address - Fax:303-364-6455
Practice Address - Street 1:11275 E MISSISSIPPI AVE
Practice Address - Street 2:2 SOUTH 3
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-3263
Practice Address - Country:US
Practice Address - Phone:303-364-6455
Practice Address - Fax:303-364-6455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO95351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty