Basic Information
| Provider Information | |||||||||
| NPI: | 1437481959 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHERIDAN DENTAL, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19266 E FAIR DR | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800163851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7204704291 | ||||||||
| FaxNumber: | 3037665599 | ||||||||
| Practice Location | |||||||||
| Address1: | 5375 W 38TH AVE | ||||||||
| Address2: | |||||||||
| City: | WHEAT RIDGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802127058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034766292 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2010 | ||||||||
| LastUpdateDate: | 02/09/2010 | ||||||||
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| AuthorizedOfficialLastName: | MANSHADI | ||||||||
| AuthorizedOfficialFirstName: | DAVOOD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DENTIST | ||||||||
| AuthorizedOfficialTelephone: | 7204704291 | ||||||||
| 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 | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.