Provider Demographics
NPI:1609390632
Name:38TH MODERN DENTAL PRACTICE, LLC
Entity Type:Organization
Organization Name:38TH MODERN DENTAL PRACTICE, LLC
Other - Org Name:38TH MODERN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:FREDERICK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-515-7008
Mailing Address - Street 1:6020 N CAREFREE CIR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80922-2402
Mailing Address - Country:US
Mailing Address - Phone:719-266-2717
Mailing Address - Fax:888-790-7062
Practice Address - Street 1:3550 W 38TH AVE.
Practice Address - Street 2:#5
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80211
Practice Address - Country:US
Practice Address - Phone:303-515-7008
Practice Address - Fax:888-790-7062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-01
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty