Provider Demographics
NPI:1730437807
Name:LAFAYETTE MODERN SMILES DENTISTRY AND ORTHODONTICS, LLP
Entity type:Organization
Organization Name:LAFAYETTE MODERN SMILES DENTISTRY AND ORTHODONTICS, LLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:HETCKO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-449-0116
Mailing Address - Street 1:17000 RED HILL AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5626
Mailing Address - Country:US
Mailing Address - Phone:714-845-8890
Mailing Address - Fax:949-474-1495
Practice Address - Street 1:1217 DIAMOND CIR UNIT 1
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-9330
Practice Address - Country:US
Practice Address - Phone:303-449-0116
Practice Address - Fax:303-449-4866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-21
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty