Provider Demographics
NPI:1396147492
Name:LONE TREE MODERN DENTAL, PROFESSIONAL
Entity type:Organization
Organization Name:LONE TREE MODERN DENTAL, PROFESSIONAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HALLINAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:720-943-2153
Mailing Address - Street 1:9227 E LINCOLN AVE
Mailing Address - Street 2:SUITE #800
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-5506
Mailing Address - Country:US
Mailing Address - Phone:720-943-2153
Mailing Address - Fax:
Practice Address - Street 1:9227 E LINCOLN AVE
Practice Address - Street 2:SUITE #800
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-5506
Practice Address - Country:US
Practice Address - Phone:720-943-2153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2019991223E0200X, 1223P0300X, 1223S0112X, 1223X0400X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO201999OtherSTATE OF COLORADO