Provider Demographics
NPI:1881747319
Name:BLUE MESA DENTISTRY AT SOUTHGLENN
Entity type:Organization
Organization Name:BLUE MESA DENTISTRY AT SOUTHGLENN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-703-4544
Mailing Address - Street 1:2001 E EASTER AVE
Mailing Address - Street 2:#200
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80122
Mailing Address - Country:US
Mailing Address - Phone:303-703-4544
Mailing Address - Fax:303-703-3610
Practice Address - Street 1:2001 E EASTER AVE
Practice Address - Street 2:#200
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80122
Practice Address - Country:US
Practice Address - Phone:303-703-4544
Practice Address - Fax:303-703-3610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6619122300000X
CO6372122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty