Provider Demographics
NPI:1790394138
Name:PROFESSIONAL DENTAL CARE OF CENTRAL COLORADO I PLLC
Entity Type:Organization
Organization Name:PROFESSIONAL DENTAL CARE OF CENTRAL COLORADO I PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARY
Authorized Official - Middle Name:
Authorized Official - Last Name:LACOUTURE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-841-0549
Mailing Address - Street 1:10940 S PARKER RD STE 121
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-7440
Mailing Address - Country:US
Mailing Address - Phone:303-841-0549
Mailing Address - Fax:303-841-0538
Practice Address - Street 1:13097 S PARKER RD UNIT A
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-7447
Practice Address - Country:US
Practice Address - Phone:303-841-0549
Practice Address - Fax:303-841-0538
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSUN HEALTH, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-07-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental