Provider Demographics
NPI:1679646582
Name:LAKE LOVELAND DERMATOLOGY PC
Entity Type:Organization
Organization Name:LAKE LOVELAND DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-569-7700
Mailing Address - Street 1:PO BOX 7643
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80537-0643
Mailing Address - Country:US
Mailing Address - Phone:970-663-2742
Mailing Address - Fax:970-342-2093
Practice Address - Street 1:1708 BOISE AVE
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-4204
Practice Address - Country:US
Practice Address - Phone:970-667-3116
Practice Address - Fax:970-669-0159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO207N00000X, 207N00000X
207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04014833Medicaid
CO04014833Medicaid
CO04014833Medicaid