Provider Demographics
NPI:1780196667
Name:PEDIATRIC DENTISTRY OF LOVELAND PLLC
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY OF LOVELAND PLLC
Other - Org Name:PEDIATRIC DENTISTRY OF LOVELAND
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:SUZANNE
Authorized Official - Last Name:GALM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-669-7711
Mailing Address - Street 1:2800 MADISON SQUARE DR STE 1
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-3358
Mailing Address - Country:US
Mailing Address - Phone:970-669-7711
Mailing Address - Fax:970-669-2491
Practice Address - Street 1:2800 MADISON SQUARE DR STE 1
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-3358
Practice Address - Country:US
Practice Address - Phone:970-669-7711
Practice Address - Fax:970-669-2491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN-96791223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03205568Medicaid
CO02009462Medicaid
CO66472270Medicaid