Provider Demographics
NPI:1932175346
Name:COMMUNITY DENTAL CLINIC, INC.
Entity Type:Organization
Organization Name:COMMUNITY DENTAL CLINIC, INC.
Other - Org Name:THE PIC PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-252-8896
Mailing Address - Street 1:87 MERCHANT DR
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-3015
Mailing Address - Country:US
Mailing Address - Phone:970-252-8896
Mailing Address - Fax:970-240-3095
Practice Address - Street 1:87 MERCHANT DR
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-3015
Practice Address - Country:US
Practice Address - Phone:970-252-8896
Practice Address - Fax:970-240-3095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-24
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO06727841Medicaid
CO2528896OtherDELTA DENTAL CHP PLUS