Provider Demographics
NPI:1992195267
Name:ALPHA DENTAL CARE V PC
Entity Type:Organization
Organization Name:ALPHA DENTAL CARE V PC
Other - Org Name:WILLOW CREEK DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKELEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-779-2797
Mailing Address - Street 1:9400 STATION ST
Mailing Address - Street 2:SUITE 175
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-6808
Mailing Address - Country:US
Mailing Address - Phone:303-779-2797
Mailing Address - Fax:303-779-2687
Practice Address - Street 1:9400 STATION ST
Practice Address - Street 2:STE 175
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-6808
Practice Address - Country:US
Practice Address - Phone:303-779-2797
Practice Address - Fax:303-779-2687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1223E0200X, 1223G0001X, 1223P0300X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty