Provider Demographics
NPI:1578004107
Name:RETRO DENTAL GROUP AVON
Entity Type:Organization
Organization Name:RETRO DENTAL GROUP AVON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELYSE
Authorized Official - Middle Name:
Authorized Official - Last Name:KESSLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-393-5128
Mailing Address - Street 1:50 BUCK CREEK RD
Mailing Address - Street 2:SUITE 305
Mailing Address - City:AVON
Mailing Address - State:CO
Mailing Address - Zip Code:81620
Mailing Address - Country:US
Mailing Address - Phone:970-393-5128
Mailing Address - Fax:
Practice Address - Street 1:50 BUCK CREEK RD
Practice Address - Street 2:SUITE 305
Practice Address - City:AVON
Practice Address - State:CO
Practice Address - Zip Code:81620
Practice Address - Country:US
Practice Address - Phone:970-393-5128
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO98326261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental