Provider Demographics
NPI:1285264242
Name:PROFESSIONAL DENTAL CARE PLLC
Entity type:Organization
Organization Name:PROFESSIONAL DENTAL CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF DENTAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:LACOURT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:414-303-7484
Mailing Address - Street 1:10940 S PARKER RD
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-7440
Mailing Address - Country:US
Mailing Address - Phone:515-371-3782
Mailing Address - Fax:
Practice Address - Street 1:550 SAINT MICHAELS DR STE 2
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7604
Practice Address - Country:US
Practice Address - Phone:505-216-2364
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-18
Last Update Date:2020-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty