Basic Information
| Provider Information | |||||||||
| NPI: | 1194966382 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 80TH AND SHERIDAN DENTAL PROF LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COMFORT DENTAL 80TH AND SHERIDAN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7990 SHERIDAN BLVD | ||||||||
| Address2: | |||||||||
| City: | WESTMINSTER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800036213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036504101 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7990 SHERIDAN BLVD | ||||||||
| Address2: | |||||||||
| City: | WESTMINSTER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800036213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036504101 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2009 | ||||||||
| LastUpdateDate: | 03/17/2009 | ||||||||
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| AuthorizedOfficialLastName: | CUBILLOS | ||||||||
| AuthorizedOfficialFirstName: | CONSTANZA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3036504101 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 9840 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.