Provider Demographics
NPI:1528265840
Name:CD LOUISVILLE PROF.
Entity type:Organization
Organization Name:CD LOUISVILLE PROF.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:MASON
Authorized Official - Last Name:DOWNEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-673-0500
Mailing Address - Street 1:339 MCCASLIN BLVD
Mailing Address - Street 2:UNIT B
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-2914
Mailing Address - Country:US
Mailing Address - Phone:303-673-0500
Mailing Address - Fax:303-673-0505
Practice Address - Street 1:339 MCCASLIN BLVD
Practice Address - Street 2:UNIT B
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-2914
Practice Address - Country:US
Practice Address - Phone:303-673-0500
Practice Address - Fax:303-673-0505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO64801223G0001X
CO94221223G0001X
CO93061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO11821078Medicaid