Provider Demographics
NPI:1194966382
Name:80TH AND SHERIDAN DENTAL PROF LLC
Entity type:Organization
Organization Name:80TH AND SHERIDAN DENTAL PROF LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CONSTANZA
Authorized Official - Middle Name:L
Authorized Official - Last Name:CUBILLOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-650-4101
Mailing Address - Street 1:7990 SHERIDAN BLVD
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80003-6213
Mailing Address - Country:US
Mailing Address - Phone:303-650-4101
Mailing Address - Fax:
Practice Address - Street 1:7990 SHERIDAN BLVD
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80003-6213
Practice Address - Country:US
Practice Address - Phone:303-650-4101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-17
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO98401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty