Provider Demographics
NPI:1740791011
Name:SUNRISE COMMUNITY HEALTH
Entity Type:Organization
Organization Name:SUNRISE COMMUNITY HEALTH
Other - Org Name:MONFORT CHILDREN'S DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-346-2546
Mailing Address - Street 1:2930 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:CO
Mailing Address - Zip Code:80620-1011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 N 11TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-2011
Practice Address - Country:US
Practice Address - Phone:970-313-0353
Practice Address - Fax:970-351-7075
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUNRISE COMMUNITY HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-10-13
Last Update Date:2023-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1223P0221X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1740791011Medicaid