Provider Demographics
NPI:1528540853
Name:ALLIANCE DENTAL GROUP
Entity Type:Organization
Organization Name:ALLIANCE DENTAL GROUP
Other - Org Name:SMILE 4 LIFE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MACUMBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-829-9243
Mailing Address - Street 1:12253 E 104TH PL UNIT 105
Mailing Address - Street 2:
Mailing Address - City:COMMERCE CITY
Mailing Address - State:CO
Mailing Address - Zip Code:80022-2096
Mailing Address - Country:US
Mailing Address - Phone:303-853-8000
Mailing Address - Fax:303-288-2219
Practice Address - Street 1:12253 E 104TH PL UNIT 105
Practice Address - Street 2:
Practice Address - City:COMMERCE CITY
Practice Address - State:CO
Practice Address - Zip Code:80022-2096
Practice Address - Country:US
Practice Address - Phone:303-853-8000
Practice Address - Fax:303-288-2219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN00202825122300000X
CODH.000903823124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty