Provider Demographics
NPI:1659817328
Name:MAIN STREET DENTAL, PC
Entity Type:Organization
Organization Name:MAIN STREET DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:LANGENFELD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-627-5460
Mailing Address - Street 1:6240 S MAIN ST
Mailing Address - Street 2:SUITE 295
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80016-5376
Mailing Address - Country:US
Mailing Address - Phone:303-627-5460
Mailing Address - Fax:303-627-5438
Practice Address - Street 1:6240 S MAIN ST
Practice Address - Street 2:SUITE 295
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80016-5376
Practice Address - Country:US
Practice Address - Phone:303-627-5460
Practice Address - Fax:303-627-5438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO104888122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO93222858Medicaid