Provider Demographics
NPI:1023491297
Name:BLUE YONDER DENTAL CARE
Entity type:Organization
Organization Name:BLUE YONDER DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:LANE
Authorized Official - Last Name:COMBS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:308-631-3833
Mailing Address - Street 1:9205 E. 159TH AVE
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:CO
Mailing Address - Zip Code:80602-8676
Mailing Address - Country:US
Mailing Address - Phone:720-836-1127
Mailing Address - Fax:720-836-3322
Practice Address - Street 1:9205 E. 159TH AVE
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80602-8676
Practice Address - Country:US
Practice Address - Phone:720-836-1127
Practice Address - Fax:720-836-3322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-06
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00006022261QD0000X
261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO932363-01Medicaid
CO93236301Medicaid