Provider Demographics
NPI:1720751282
Name:POOR, LILLY ANNA (DMD)
Entity Type:Individual
Prefix:DR
First Name:LILLY
Middle Name:ANNA
Last Name:POOR
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11226 UPTOWN AVE
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80021-4247
Mailing Address - Country:US
Mailing Address - Phone:812-322-2955
Mailing Address - Fax:
Practice Address - Street 1:421 W 104TH AVE STE 201
Practice Address - Street 2:
Practice Address - City:NORTHGLENN
Practice Address - State:CO
Practice Address - Zip Code:80234-4138
Practice Address - Country:US
Practice Address - Phone:303-872-5970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-29
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0111551223G0001X
CODEN.00205791122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice