Provider Demographics
NPI:1962819383
Name:ASPEN TO PARACHUTE DENTAL HEALTH ALLIANCE
Entity Type:Organization
Organization Name:ASPEN TO PARACHUTE DENTAL HEALTH ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL ORAL HEALTH CONSULTATN
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:KEEFFE
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:970-309-2064
Mailing Address - Street 1:PO BOX 1251
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81602-1251
Mailing Address - Country:US
Mailing Address - Phone:970-309-2064
Mailing Address - Fax:
Practice Address - Street 1:20 EAGLE COUNTY RD
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:CO
Practice Address - Zip Code:81623-9125
Practice Address - Country:US
Practice Address - Phone:970-309-2064
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH3120124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO90721756Medicaid