Provider Demographics
NPI:1144640210
Name:COMMERCE CITY FAMILY DENTAL, L.L.C.
Entity type:Organization
Organization Name:COMMERCE CITY FAMILY DENTAL, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:KARLA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:303-288-4969
Mailing Address - Street 1:4972 E. 62ND AVE.
Mailing Address - Street 2:STE. B-1
Mailing Address - City:COMMERCE CITY
Mailing Address - State:CO
Mailing Address - Zip Code:80022
Mailing Address - Country:US
Mailing Address - Phone:303-288-4969
Mailing Address - Fax:303-286-6727
Practice Address - Street 1:4972 E. 62ND AVE.
Practice Address - Street 2:STE. B-1
Practice Address - City:COMMERCE CITY
Practice Address - State:CO
Practice Address - Zip Code:80022
Practice Address - Country:US
Practice Address - Phone:303-288-4969
Practice Address - Fax:303-286-6727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-16
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO37433741Medicaid