Provider Demographics
NPI:1770791790
Name:COLORADO DENTAL PROFESSIONALS, LLC
Entity type:Organization
Organization Name:COLORADO DENTAL PROFESSIONALS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING TEAM LEAD
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8972
Mailing Address - Street 1:18525 E SMOKY HILL RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80015-3108
Mailing Address - Country:US
Mailing Address - Phone:303-617-9090
Mailing Address - Fax:303-617-9838
Practice Address - Street 1:18525 E SMOKY HILL RD
Practice Address - Street 2:SUITE D
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80015-3108
Practice Address - Country:US
Practice Address - Phone:303-617-9090
Practice Address - Fax:303-617-9838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO70991223G0001X
COCO72821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1700878626OtherDANIEL B NORRIE
CO1861494494OtherROB C MULLINS