Provider Demographics
NPI:1104086198
Name:SILVERTHORNE DENTAL PARTNERS PROF LLP
Entity type:Organization
Organization Name:SILVERTHORNE DENTAL PARTNERS PROF LLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER OWNER DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MUNDY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-262-2273
Mailing Address - Street 1:PO BOX 1548
Mailing Address - Street 2:354 BLUE RIVER PARKWAY
Mailing Address - City:SILVERTHORNE
Mailing Address - State:CO
Mailing Address - Zip Code:80498-1548
Mailing Address - Country:US
Mailing Address - Phone:970-262-2273
Mailing Address - Fax:970-262-3866
Practice Address - Street 1:354 BLUE RIVER PARKWAY
Practice Address - Street 2:
Practice Address - City:SILVERTHORNE
Practice Address - State:CO
Practice Address - Zip Code:80498-1548
Practice Address - Country:US
Practice Address - Phone:970-262-2273
Practice Address - Fax:970-262-3866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-12
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO61871223G0001X
CO74931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02061877Medicaid
CO02074938Medicaid