Provider Demographics
NPI:1679204317
Name:MOUNTAIN STREAM DENTAL CARE PLLC
Entity Type:Organization
Organization Name:MOUNTAIN STREAM DENTAL CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LEILA
Authorized Official - Middle Name:
Authorized Official - Last Name:MACARIO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:954-599-9530
Mailing Address - Street 1:791 W KELLY RD
Mailing Address - Street 2:
Mailing Address - City:WOODLAND PARK
Mailing Address - State:CO
Mailing Address - Zip Code:80863-3014
Mailing Address - Country:US
Mailing Address - Phone:719-687-9011
Mailing Address - Fax:
Practice Address - Street 1:791 W KELLY RD
Practice Address - Street 2:
Practice Address - City:WOODLAND PARK
Practice Address - State:CO
Practice Address - Zip Code:80863-3014
Practice Address - Country:US
Practice Address - Phone:719-687-9011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty