Provider Demographics
NPI:1669026332
Name:MY LOCAL COLORADO DENTAL PRACTICE, LLC
Entity type:Organization
Organization Name:MY LOCAL COLORADO DENTAL PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-315-8338
Mailing Address - Street 1:1600 23RD AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-6071
Mailing Address - Country:US
Mailing Address - Phone:970-353-4329
Mailing Address - Fax:
Practice Address - Street 1:1600 23RD AVE STE 200
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-6071
Practice Address - Country:US
Practice Address - Phone:970-353-4329
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MY LOCAL COLORADO DENTAL PRACTICE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty