Provider Demographics
NPI:1215240882
Name:NEW IMAGE DENTAL IMPLANT CENTER
Entity type:Organization
Organization Name:NEW IMAGE DENTAL IMPLANT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-321-8400
Mailing Address - Street 1:3737 E 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-7510
Mailing Address - Country:US
Mailing Address - Phone:303-321-8400
Mailing Address - Fax:
Practice Address - Street 1:3737 E 1ST AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-7510
Practice Address - Country:US
Practice Address - Phone:303-321-8400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-23
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO-1042141223P0700X
COCO-71491223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCO-104214OtherSTARE LICENSE DR.DOBRO
COCO-7149OtherSTATE LICENSE DR. STEIN