Provider Demographics
NPI:1205485612
Name:AT HOME MOBILE DENTAL CORP.
Entity type:Organization
Organization Name:AT HOME MOBILE DENTAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHANIEL
Authorized Official - Middle Name:CONRAD
Authorized Official - Last Name:CEJKA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:720-666-1162
Mailing Address - Street 1:18551 E MAINSTREET # 103
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-4951
Mailing Address - Country:US
Mailing Address - Phone:720-666-1162
Mailing Address - Fax:
Practice Address - Street 1:18551 E MAINSTREET # 103
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-4951
Practice Address - Country:US
Practice Address - Phone:720-666-1162
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty