Provider Demographics
NPI:1851962310
Name:PEDODENT PC
Entity Type:Organization
Organization Name:PEDODENT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-422-6752
Mailing Address - Street 1:8723 WADSWORTH BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80003-0921
Mailing Address - Country:US
Mailing Address - Phone:303-422-6752
Mailing Address - Fax:
Practice Address - Street 1:2700 E BRIDGE ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601-2591
Practice Address - Country:US
Practice Address - Phone:303-659-7700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-06
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1225013451OtherPEDIATRIC DENTISTRY