Provider Demographics
NPI:1922244193
Name:MOUNTAIN DENTAL PC
Entity Type:Organization
Organization Name:MOUNTAIN DENTAL PC
Other - Org Name:MOUNTAIN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROFESSIONAL SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:PELKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-926-5050
Mailing Address - Street 1:300 NICKEL ST STE 11
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-2097
Mailing Address - Country:US
Mailing Address - Phone:303-635-1816
Mailing Address - Fax:
Practice Address - Street 1:300 NICKEL ST STE 11
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-2097
Practice Address - Country:US
Practice Address - Phone:303-635-1816
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOUNTAIN DENTAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-18
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty