Provider Demographics
NPI:1326211863
Name:PEDIATRIC DENTAL GROUP OF LAFAYETTE
Entity type:Organization
Organization Name:PEDIATRIC DENTAL GROUP OF LAFAYETTE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTSHORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-890-9494
Mailing Address - Street 1:300 EXEMPLA CIR STE 460
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-3396
Mailing Address - Country:US
Mailing Address - Phone:720-890-9494
Mailing Address - Fax:720-890-1444
Practice Address - Street 1:300 EXEMPLA CIR STE 460
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026
Practice Address - Country:US
Practice Address - Phone:720-890-9494
Practice Address - Fax:720-890-1444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-04
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO39021378Medicaid