NPIMap

Organization Active NPI

My Local Colorado Dental Practice, LLC

Doing business as College Ave Modern Dental

  • General Practice Dentistry
  • Fort Collins, CO
National Provider Identifier
1548814262
Registry record updated Jul 31, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
Legal business name
MY LOCAL COLORADO DENTAL PRACTICE, LLC
Doing business as
College Ave Modern Dental
Practice address
3617 S College Ave Unit B
Fort Collins, CO 80525-3009
Phone
(970) 233-8933
NPI assigned
Jul 31, 2019
Last updated
Jul 31, 2019By the provider in NPPES
Organization subpart
Yes
Parent organization
MY LOCAL COLORADO DENTAL PRACTICE, LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jul 31, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Michelle Johnson
Title
Credentialing Specialist
Phone
(509) 315-8338

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice Dentistry 1223G0001X NU Primary

Addresses

Primary practice location

3617 S College Ave Unit B
Fort Collins, CO 80525-3009

Mailing address

3617 S College Ave Unit B
Fort Collins, CO 80525-3009

Other names 1

  • College Ave Modern Dental Doing business as

National Provider Directory

National Provider Directory
Tax ID family
My Local Colorado Dental Practice LLC40 organizations share this tax ID, including this one
Part of
My Local Colorado Dental Practice LLC

Other organizations with this tax ID 39

Organizations that report the same tax identification number in the National Provider Directory.

View all 39

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1564531200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1564531200000",
    "number": "1548814262",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3617 S COLLEGE AVE UNIT B",
            "city": "FORT COLLINS",
            "state": "CO",
            "postal_code": "805253009"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3617 S COLLEGE AVE UNIT B",
            "city": "FORT COLLINS",
            "state": "CO",
            "postal_code": "805253009",
            "telephone_number": "970-233-8933"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MY LOCAL COLORADO DENTAL PRACTICE, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MY LOCAL COLORADO DENTAL PRACTICE, LLC",
        "enumeration_date": "2019-07-31",
        "last_updated": "2019-07-31",
        "status": "A",
        "authorized_official_last_name": "JOHNSON",
        "authorized_official_first_name": "MICHELLE",
        "authorized_official_title_or_position": "CREDENTIALING SPECIALIST",
        "authorized_official_telephone_number": "509-315-8338"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "College Ave Modern Dental",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fort Collins, CO

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 31, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.