Provider Demographics
NPI:1811329121
Name:WOODLAND PARK DENTAL PROFESSIONAL LLC
Entity type:Organization
Organization Name:WOODLAND PARK DENTAL PROFESSIONAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:PEAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-484-8490
Mailing Address - Street 1:150 MORNING SUN DR
Mailing Address - Street 2:SUITE 200W
Mailing Address - City:WOODLAND PARK
Mailing Address - State:CO
Mailing Address - Zip Code:80863-9160
Mailing Address - Country:US
Mailing Address - Phone:719-484-8490
Mailing Address - Fax:888-790-7062
Practice Address - Street 1:150 MORNING SUN DR
Practice Address - Street 2:SUITE 200W
Practice Address - City:WOODLAND PARK
Practice Address - State:CO
Practice Address - Zip Code:80863-9160
Practice Address - Country:US
Practice Address - Phone:719-484-8490
Practice Address - Fax:888-790-7062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-08
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
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