Basic Information
| Provider Information | |||||||||
| NPI: | 1629456298 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TERRY DENTAL LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ELIZABETH FAMILY DENTAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 210 ELIZABETH ST | ||||||||
| Address2: | ST E. | ||||||||
| City: | ELIZABETH | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801077538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036466336 | ||||||||
| FaxNumber: | 3036465355 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 ELIZABETH ST | ||||||||
| Address2: | ST E | ||||||||
| City: | ELIZABETH | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801077538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036466336 | ||||||||
| FaxNumber: | 3036465355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2015 | ||||||||
| LastUpdateDate: | 05/14/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TERRY | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | BOONE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3036466336 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DMD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 10143 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.