Provider Demographics
NPI:1942544507
Name:PRAIRIE HAWK DENTAL PLLC
Entity Type:Organization
Organization Name:PRAIRIE HAWK DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AARON
Authorized Official - Middle Name:PIERCE
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:720-515-1801
Mailing Address - Street 1:3993 LIMELIGHT AVE.
Mailing Address - Street 2:UNIT E
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80109
Mailing Address - Country:US
Mailing Address - Phone:720-515-1801
Mailing Address - Fax:
Practice Address - Street 1:3993 LIMELIGHT AVE.
Practice Address - Street 2:UNIT E
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80109
Practice Address - Country:US
Practice Address - Phone:720-515-1801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-20
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO104021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty