Provider Demographics
NPI:1811972094
Name:SOUTHMOOR PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:SOUTHMOOR PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:R
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-799-1872
Mailing Address - Street 1:6850 E HAMPDEN AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80224-3024
Mailing Address - Country:US
Mailing Address - Phone:303-758-6057
Mailing Address - Fax:303-692-9655
Practice Address - Street 1:6850 E HAMPDEN AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80224-3024
Practice Address - Country:US
Practice Address - Phone:303-758-6057
Practice Address - Fax:303-692-9655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-12
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO049491223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty