Provider Demographics
NPI:1982200531
Name:COLORADO DENTAL PROFESSIONALS, LLC
Entity Type:Organization
Organization Name:COLORADO DENTAL PROFESSIONALS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TABATHA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEMKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-6078
Mailing Address - Street 1:1140 W SOUTH BOULDER RD STE 201
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-8910
Mailing Address - Country:US
Mailing Address - Phone:720-623-1140
Mailing Address - Fax:
Practice Address - Street 1:1140 W SOUTH BOULDER RD STE 201
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-8910
Practice Address - Country:US
Practice Address - Phone:720-623-1140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLORADO DENTAL PROFESSIONALS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty