Provider Demographics
NPI:1922128859
Name:PERFECT TEETH - EAST 104TH AVENUE P.C.
Entity Type:Organization
Organization Name:PERFECT TEETH - EAST 104TH AVENUE P.C.
Other - Org Name:PERFECT TEETH - EAST 104TH AVENUE P.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SUMMERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-285-6098
Mailing Address - Street 1:2200 E 104TH AVE
Mailing Address - Street 2:#112
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80233-4404
Mailing Address - Country:US
Mailing Address - Phone:303-452-4142
Mailing Address - Fax:303-254-8360
Practice Address - Street 1:2200 E 104TH AVE
Practice Address - Street 2:#112
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80233-4404
Practice Address - Country:US
Practice Address - Phone:303-452-4142
Practice Address - Fax:303-254-8360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO60971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty