Provider Demographics
NPI:1366527400
Name:PREVENTIVE FAMILY DENTAL PC
Entity type:Organization
Organization Name:PREVENTIVE FAMILY DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HUDDLESTON
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:719-346-7746
Mailing Address - Street 1:PO BOX 94
Mailing Address - Street 2:1440 LOWELL AVE
Mailing Address - City:BURLINGTON
Mailing Address - State:CO
Mailing Address - Zip Code:80807-0094
Mailing Address - Country:US
Mailing Address - Phone:719-346-7746
Mailing Address - Fax:719-346-5360
Practice Address - Street 1:1440 LOWELL AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:CO
Practice Address - Zip Code:80807-0094
Practice Address - Country:US
Practice Address - Phone:719-346-7746
Practice Address - Fax:719-346-5360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2986124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO21420025Medicaid
CO29686873Medicaid