Provider Demographics
NPI:1538655592
Name:NORTHGLENN DENTISTRY AND ORTHODONTICS PLLC
Entity Type:Organization
Organization Name:NORTHGLENN DENTISTRY AND ORTHODONTICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:FAITH
Authorized Official - Middle Name:
Authorized Official - Last Name:GASKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-869-3789
Mailing Address - Street 1:2403 LACY LN
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75006-6514
Mailing Address - Country:US
Mailing Address - Phone:972-869-3789
Mailing Address - Fax:
Practice Address - Street 1:421 W 104TH AVE STE 201
Practice Address - Street 2:
Practice Address - City:NORTHGLENN
Practice Address - State:CO
Practice Address - Zip Code:80234-4138
Practice Address - Country:US
Practice Address - Phone:303-427-6462
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-02
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2019971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty