Provider Demographics
NPI:1558870188
Name:COLORADO DENTAL PROFESSIONALS, LLC
Entity Type:Organization
Organization Name:COLORADO DENTAL PROFESSIONALS, LLC
Other - Org Name:ADVANCED DENTAL ON SMOKY HILL ROAD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8972
Mailing Address - Street 1:20921 E SMOKY HILL RD UNIT A
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80015-5126
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20921 E SMOKY HILL RD UNIT A
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80015-5126
Practice Address - Country:US
Practice Address - Phone:303-690-7778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLORADO DENTAL PROFESSIONALS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-27
Last Update Date:2017-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty