Provider Demographics
NPI:1881717007
Name:PEDIATRIC DENTISTRY, P.C.
Entity type:Organization
Organization Name:PEDIATRIC DENTISTRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY-TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:IRA
Authorized Official - Middle Name:N
Authorized Official - Last Name:MOYER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-973-4424
Mailing Address - Street 1:10184 W BELLEVIEW AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80127-1700
Mailing Address - Country:US
Mailing Address - Phone:303-973-4424
Mailing Address - Fax:303-973-4427
Practice Address - Street 1:10184 W BELLEVIEW AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80127-1700
Practice Address - Country:US
Practice Address - Phone:303-973-4424
Practice Address - Fax:303-973-4427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1049771223X0400X, 1223P0221X
CO1049781223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Not Answered1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02049781Medicaid