Basic Information
| Provider Information | |||||||||
| NPI: | 1295092955 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KIDS FIRST DENTAL, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9362 S COLORADO BLVD UNIT D14 | ||||||||
| Address2: | |||||||||
| City: | HIGHLANDS RANCH | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801265207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034276300 | ||||||||
| FaxNumber: | 7203442663 | ||||||||
| Practice Location | |||||||||
| Address1: | 9362 S COLORADO BLVD UNIT D14 | ||||||||
| Address2: | |||||||||
| City: | HIGHLANDS RANCH | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801265207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034276300 | ||||||||
| FaxNumber: | 7203442663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2012 | ||||||||
| LastUpdateDate: | 04/19/2012 | ||||||||
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| AuthorizedOfficialLastName: | SHORT | ||||||||
| AuthorizedOfficialFirstName: | YOLANDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3034276300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | 9758 | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
ID Information
| ID | Type | State | Issuer | Description | 56201346 | 05 | CO | MEDICAID |