Provider Demographics
NPI:1215138250
Name:STODDARD, DENNIS G (DDS)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:G
Last Name:STODDARD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2295 S CHAMBERS RD
Mailing Address - Street 2:#E
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-4544
Mailing Address - Country:US
Mailing Address - Phone:303-751-6511
Mailing Address - Fax:
Practice Address - Street 1:625 E ALAMEDA RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3622
Practice Address - Country:US
Practice Address - Phone:208-237-1567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8647122300000X, 1223G0001X
IDD-4186-PD1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO11854014Medicaid