Provider Demographics
NPI:1700921707
Name:COLORADO DHCA, 16TH STREET MALL, PLLC
Entity type:Organization
Organization Name:COLORADO DHCA, 16TH STREET MALL, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JUNIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-592-1133
Mailing Address - Street 1:1600 STOUT ST STE 600
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80202-3106
Mailing Address - Country:US
Mailing Address - Phone:303-592-1133
Mailing Address - Fax:303-592-1265
Practice Address - Street 1:1600 STOUT ST STE 600
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80202-3106
Practice Address - Country:US
Practice Address - Phone:303-592-1133
Practice Address - Fax:303-592-1265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO841525799OtherSPECIALITY