Provider Demographics
NPI:1891003570
Name:GREEN MOUNTAIN DENTAL PROF. LLC
Entity Type:Organization
Organization Name:GREEN MOUNTAIN DENTAL PROF. LLC
Other - Org Name:COMFORT DENTAL GREEN MOUNTAIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:KLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-727-9100
Mailing Address - Street 1:12810 W ALAMEDA PKWY
Mailing Address - Street 2:UNIT A
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-3116
Mailing Address - Country:US
Mailing Address - Phone:303-727-9100
Mailing Address - Fax:303-727-8636
Practice Address - Street 1:12810 W ALAMEDA PKWY
Practice Address - Street 2:UNIT A
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-3116
Practice Address - Country:US
Practice Address - Phone:303-727-9100
Practice Address - Fax:303-727-8636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO105192122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty