Provider Demographics
NPI:1386706430
Name:SOUTH FEDERAL DENTAL GP PC
Entity type:Organization
Organization Name:SOUTH FEDERAL DENTAL GP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:L
Authorized Official - Last Name:FARMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-934-0232
Mailing Address - Street 1:1601 SO FEDERAL BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80219
Mailing Address - Country:US
Mailing Address - Phone:303-934-0232
Mailing Address - Fax:303-934-2208
Practice Address - Street 1:1601 SO FEDERAL BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80219
Practice Address - Country:US
Practice Address - Phone:303-934-0232
Practice Address - Fax:303-934-2208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1054151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04001301Medicaid