Provider Demographics
NPI:1679731764
Name:PEDIATRIC DENTAL ASSOCIATES OF COLORADO
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL ASSOCIATES OF COLORADO
Other - Org Name:CHILDREN'S DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLSON-MARKS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-594-2214
Mailing Address - Street 1:730 POTOMAC ST
Mailing Address - Street 2:#306
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80011-6703
Mailing Address - Country:US
Mailing Address - Phone:303-537-0234
Mailing Address - Fax:720-858-8248
Practice Address - Street 1:3795 S COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-4202
Practice Address - Country:US
Practice Address - Phone:303-522-4703
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO73961223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04474562Medicaid
CO71905774Medicaid
CO56982771Medicaid
CO55931375Medicaid