Basic Information
| Provider Information | |||||||||
| NPI: | 1790944585 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EMBRACE KIDS, A PROFESSIONAL LLC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ALL ABOUT BRACES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 WADSWORTH BLVD | ||||||||
| Address2: | SUITE 18-A | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802145728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034621462 | ||||||||
| FaxNumber: | 3039975646 | ||||||||
| Practice Location | |||||||||
| Address1: | 2020 WADSWORTH BLVD | ||||||||
| Address2: | SUITE 18A | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802145728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034621462 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2008 | ||||||||
| LastUpdateDate: | 12/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | MADRIGAL | ||||||||
| AuthorizedOfficialFirstName: | YVETTE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3034621462 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X | 6889 | CO | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics | 1223X0400X | 9257 | CO | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics | 1223X0400X | 9224 | CO | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
ID Information
| ID | Type | State | Issuer | Description | 84923369 | 05 | CO | MEDICAID |