Provider Demographics
NPI:1043792815
Name:ASSADOGHLI, ARACE NANA (DMD)
Entity type:Individual
Prefix:DR
First Name:ARACE
Middle Name:NANA
Last Name:ASSADOGHLI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32527 LITTLE CUB RD
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-6657
Mailing Address - Country:US
Mailing Address - Phone:904-710-5632
Mailing Address - Fax:
Practice Address - Street 1:4490 W 121ST AVE STE 7
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-5603
Practice Address - Country:US
Practice Address - Phone:303-469-2061
Practice Address - Fax:303-275-8011
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN23786122300000X
CODEN002047431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentistGroup - Single Specialty