Provider Demographics
NPI:1598040578
Name:JILL K. MIODUSKI, DDS, MS, PROFESSIONAL LLC
Entity Type:Organization
Organization Name:JILL K. MIODUSKI, DDS, MS, PROFESSIONAL LLC
Other - Org Name:NORTHERN COLORADO ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ORTHODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:K
Authorized Official - Last Name:MIODUSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:970-674-0717
Mailing Address - Street 1:1295 MAIN ST
Mailing Address - Street 2:#4
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80550-5966
Mailing Address - Country:US
Mailing Address - Phone:970-674-0717
Mailing Address - Fax:
Practice Address - Street 1:1295 MAIN ST
Practice Address - Street 2:#4
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-5966
Practice Address - Country:US
Practice Address - Phone:970-674-0717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO101781223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty