Basic Information
| Provider Information | |||||||||
| NPI: | 1104106095 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREEN VALLEY RANCH MODERN SMILES AND ORTHODONTICS, LLP | ||||||||
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| OtherOrganizationName: | GREEN VALLEY RANCH MODERN SMILES AND ORTHODONTICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2860 MICHELLE FL 2 | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926061008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7143682077 | ||||||||
| FaxNumber: | 7143682092 | ||||||||
| Practice Location | |||||||||
| Address1: | 3445 SALIDA ST STE 30 | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800115000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033663383 | ||||||||
| FaxNumber: | 3033659521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2011 | ||||||||
| LastUpdateDate: | 08/23/2011 | ||||||||
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| AuthorizedOfficialLastName: | MCCANN | ||||||||
| AuthorizedOfficialFirstName: | KATIE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 3033663383 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.