Basic Information
Provider Information | |||||||||
NPI: | 1760489660 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KAZI | ||||||||
FirstName: | FATIMA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.D.S. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LEE | ||||||||
OtherFirstName: | FATIMA | ||||||||
OtherMiddleName: | KAZI | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | D.D.S. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 3701 S BROADWAY | ||||||||
Address2: |   | ||||||||
City: | ENGLEWOOD | ||||||||
State: | CO | ||||||||
PostalCode: | 801133611 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3033606276 | ||||||||
FaxNumber: | 3034675355 | ||||||||
Practice Location | |||||||||
Address1: | 7495 W 29TH AVE | ||||||||
Address2: |   | ||||||||
City: | WHEAT RIDGE | ||||||||
State: | CO | ||||||||
PostalCode: | 800338002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3032399964 | ||||||||
FaxNumber: | 3032374343 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2005 | ||||||||
LastUpdateDate: | 08/05/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DEN.00008299 | CO | Y |   | Dental Providers | Dentist |   |
ID Information
ID | Type | State | Issuer | Description | 15258530 | 05 | CO |   | MEDICAID |