Provider Demographics
NPI:1689012122
Name:KIDS TOOTH DOC
Entity Type:Organization
Organization Name:KIDS TOOTH DOC
Other - Org Name:CHILDRENS DENTAL SPECIALIST OF COLORADO
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-947-7705
Mailing Address - Street 1:5168 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113-6706
Mailing Address - Country:US
Mailing Address - Phone:303-974-5868
Mailing Address - Fax:
Practice Address - Street 1:5168 S BROADWAY
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-6706
Practice Address - Country:US
Practice Address - Phone:303-974-5868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-06
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO92133312Medicaid