Provider Demographics
NPI:1922642743
Name:MOUNTAIN DENTAL ANESTHESIA LLC
Entity Type:Organization
Organization Name:MOUNTAIN DENTAL ANESTHESIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST ANESTHESIOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:YANCEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-459-0738
Mailing Address - Street 1:7787 W 106TH AVE
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80021-3951
Mailing Address - Country:US
Mailing Address - Phone:317-459-0738
Mailing Address - Fax:
Practice Address - Street 1:11001 W 120TH AVE STE 400
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80021-3493
Practice Address - Country:US
Practice Address - Phone:317-459-0738
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOUNTAIN DENTAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty