Provider Demographics
NPI:1922247758
Name:TREASURED TEETH PC
Entity Type:Organization
Organization Name:TREASURED TEETH PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DERREN
Authorized Official - Middle Name:ELVIS
Authorized Official - Last Name:TIPPETS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:970-240-8694
Mailing Address - Street 1:100 TESSITORE CT UNIT C
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-5689
Mailing Address - Country:US
Mailing Address - Phone:970-240-8694
Mailing Address - Fax:970-240-8696
Practice Address - Street 1:100 TESSITORE CT UNIT C
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-5689
Practice Address - Country:US
Practice Address - Phone:970-240-8694
Practice Address - Fax:970-240-8696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO95791223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty