Provider Demographics
NPI:1548691520
Name:PROFESSIONAL DENTAL GROUP
Entity type:Organization
Organization Name:PROFESSIONAL DENTAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-638-2169
Mailing Address - Street 1:1120 W SOUTH BOULDER RD STE 204
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-8952
Mailing Address - Country:US
Mailing Address - Phone:720-638-2169
Mailing Address - Fax:720-638-2931
Practice Address - Street 1:1120 W SOUTH BOULDER RD STE 204
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-8952
Practice Address - Country:US
Practice Address - Phone:720-638-2169
Practice Address - Fax:720-638-2931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-02
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7990122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty