Provider Demographics
NPI:1992195507
Name:LINCOLN AVE DENTISTRY
Entity Type:Organization
Organization Name:LINCOLN AVE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:720-638-2075
Mailing Address - Street 1:16522 KEYSTONE BLVD
Mailing Address - Street 2:UNIT T
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-3303
Mailing Address - Country:US
Mailing Address - Phone:720-638-2075
Mailing Address - Fax:303-284-2540
Practice Address - Street 1:16522 KEYSTONE BLVD
Practice Address - Street 2:UNIT T
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-3303
Practice Address - Country:US
Practice Address - Phone:720-638-2075
Practice Address - Fax:303-284-2540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-03
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN 10365122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty