Provider Demographics
NPI:1992961940
Name:FALLIN, LONNIE DALE (DDS)
Entity type:Individual
Prefix:DR
First Name:LONNIE
Middle Name:DALE
Last Name:FALLIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6162 SO. WILLOW DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GREENWOOD VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:80111
Mailing Address - Country:US
Mailing Address - Phone:303-220-9200
Mailing Address - Fax:303-741-4173
Practice Address - Street 1:6162 SO. WILLOW DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111
Practice Address - Country:US
Practice Address - Phone:303-220-9200
Practice Address - Fax:303-741-4173
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-30
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO356122300000X
CO0000356122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist