Provider Demographics
NPI:1740305820
Name:IMAGE DENTAL
Entity type:Organization
Organization Name:IMAGE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGUIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-926-5437
Mailing Address - Street 1:56 EDWARDS VILLAGE BLVD
Mailing Address - Street 2:SUITE 216
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-7802
Mailing Address - Country:US
Mailing Address - Phone:970-926-5437
Mailing Address - Fax:970-926-7960
Practice Address - Street 1:56 EDWARDS VILLAGE BLVD
Practice Address - Street 2:SUITE 216
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632-7802
Practice Address - Country:US
Practice Address - Phone:970-926-5437
Practice Address - Fax:970-926-7960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7805261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental