Provider Demographics
NPI:1629456298
Name:TERRY DENTAL LLC
Entity type:Organization
Organization Name:TERRY DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:BOONE
Authorized Official - Last Name:TERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:303-646-6336
Mailing Address - Street 1:210 ELIZABETH ST
Mailing Address - Street 2:ST E.
Mailing Address - City:ELIZABETH
Mailing Address - State:CO
Mailing Address - Zip Code:80107-7538
Mailing Address - Country:US
Mailing Address - Phone:303-646-6336
Mailing Address - Fax:303-646-5355
Practice Address - Street 1:210 ELIZABETH ST
Practice Address - Street 2:ST E
Practice Address - City:ELIZABETH
Practice Address - State:CO
Practice Address - Zip Code:80107-7538
Practice Address - Country:US
Practice Address - Phone:303-646-6336
Practice Address - Fax:303-646-5355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO101431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO=========OtherFEIN