Provider Demographics
NPI:1669977427
Name:A COUNTRY DENTIST, PLLC
Entity type:Organization
Organization Name:A COUNTRY DENTIST, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:PASCO
Authorized Official - Middle Name:W
Authorized Official - Last Name:SCARPELLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-335-8160
Mailing Address - Street 1:107 W 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MORGAN
Mailing Address - State:CO
Mailing Address - Zip Code:80701-2011
Mailing Address - Country:US
Mailing Address - Phone:970-867-2502
Mailing Address - Fax:970-867-3795
Practice Address - Street 1:107 W 9TH AVE
Practice Address - Street 2:
Practice Address - City:FORT MORGAN
Practice Address - State:CO
Practice Address - Zip Code:80701-2011
Practice Address - Country:US
Practice Address - Phone:970-867-2502
Practice Address - Fax:970-867-3795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO106313261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO32871716Medicaid