Provider Demographics
NPI:1639847510
Name:COLORADO DENTAL TEAM PROFESSIONAL
Entity Type:Organization
Organization Name:COLORADO DENTAL TEAM PROFESSIONAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KETAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SUKKAWALA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:979-450-1116
Mailing Address - Street 1:182 INDUSTRIAL RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ROCK
Mailing Address - State:PA
Mailing Address - Zip Code:17327-8626
Mailing Address - Country:US
Mailing Address - Phone:717-759-4375
Mailing Address - Fax:717-759-4336
Practice Address - Street 1:10170 CHURCH RANCH WAY UNIT 110
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80021-6059
Practice Address - Country:US
Practice Address - Phone:720-330-5571
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-03
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty