Provider Demographics
NPI:1720214638
Name:PEDIATRIC DENTAL GROUP OF LAKEWOOD
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL GROUP OF LAKEWOOD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:E
Authorized Official - Last Name:HARTSHORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-338-9778
Mailing Address - Street 1:3333 S WADSWORTH BLVD UNIT B102B104
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80227-5122
Mailing Address - Country:US
Mailing Address - Phone:303-984-9700
Mailing Address - Fax:303-985-2490
Practice Address - Street 1:3333 S WADSWORTH BLVD UNIT B104
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80227-5120
Practice Address - Country:US
Practice Address - Phone:303-984-9700
Practice Address - Fax:303-985-2490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-05
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO44332866Medicaid
CO02006518Medicaid
CO02078434Medicaid
CO38371847Medicaid
CO83777709Medicaid