Provider Demographics
NPI:1891749040
Name:IMPLANT AND GENERAL DENTISTRY OF NORTHERN COLORADO
Entity Type:Organization
Organization Name:IMPLANT AND GENERAL DENTISTRY OF NORTHERN COLORADO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:MIODUSKI
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-663-1000
Mailing Address - Street 1:2975 GINNALA DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-3300
Mailing Address - Country:US
Mailing Address - Phone:970-663-1000
Mailing Address - Fax:970-663-0615
Practice Address - Street 1:2975 GINNALA DR STE 100
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-3300
Practice Address - Country:US
Practice Address - Phone:970-663-1000
Practice Address - Fax:970-663-0615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO1057151223G0001X
COCO82851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty