Basic Information
| Provider Information | |||||||||
| NPI: | 1356947782 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMBRACE KIDS, A PROFESSIONAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 WADSWORTH BLVD STE 18A | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802145730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034621462 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2020 WADSWORTH BLVD STE 18A | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802145730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034621462 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2020 | ||||||||
| LastUpdateDate: | 12/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | NIEBERG | ||||||||
| AuthorizedOfficialFirstName: | OWEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 3034766233 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EMBRACE KIDS, A PROFESSIONAL LLC | ||||||||
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| NPICertificationDate: | 12/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
No ID Information.