Provider Demographics
NPI:1619357555
Name:BRACES4KIDS, PLLC
Entity type:Organization
Organization Name:BRACES4KIDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:H
Authorized Official - Last Name:JOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:970-523-6333
Mailing Address - Street 1:601 28 1/4 RD UNIT E
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-6022
Mailing Address - Country:US
Mailing Address - Phone:970-523-6333
Mailing Address - Fax:970-243-3008
Practice Address - Street 1:2400 W 16TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-6067
Practice Address - Country:US
Practice Address - Phone:970-523-6333
Practice Address - Fax:970-243-3008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-05
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO107181223X0400X
CO91431223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1588763528Medicaid
CO1154675874Medicaid