Provider Demographics
NPI:1942459490
Name:EVERGREEN FAMILY DENTISTRY PC
Entity Type:Organization
Organization Name:EVERGREEN FAMILY DENTISTRY PC
Other - Org Name:S CORPORATION
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-674-3591
Mailing Address - Street 1:PO BOX 3958
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80437
Mailing Address - Country:US
Mailing Address - Phone:303-674-3591
Mailing Address - Fax:303-674-9650
Practice Address - Street 1:3720 EVERGREEN PARKWAY
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439
Practice Address - Country:US
Practice Address - Phone:303-674-3591
Practice Address - Fax:303-674-9650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO6701122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty