Provider Demographics
NPI:1790288744
Name:SEVERANCE DENTAL, PLLC
Entity Type:Organization
Organization Name:SEVERANCE DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:CHAD
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-295-1099
Mailing Address - Street 1:1581 WINDSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80550-5823
Mailing Address - Country:US
Mailing Address - Phone:502-295-1099
Mailing Address - Fax:
Practice Address - Street 1:375 W 4TH AVE
Practice Address - Street 2:
Practice Address - City:SEVERANCE
Practice Address - State:CO
Practice Address - Zip Code:80550-2949
Practice Address - Country:US
Practice Address - Phone:970-693-0080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty