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Provider Information for 1790932879

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1790932879

Calendar   Last Updated:  2012-02-15
  Certification Date: 


Name Value
NPI 1790932879
Enumeration Date 2008-08-20
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 2801 E 120TH AVE #I 303
THORNTON, CO 80233-1499
United States

Phone: 949-878-6661 | Fax:
View Map External Link
Primary Practice Address 14422 ORCHARD PKWY SUITE 200
WESTMINSTER, CO 80023-9273
United States

Phone: 303-659-3003 | Fax:
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 122300000X - Dentist CO 10603
No 122300000X - Dentist CA 57599