Provider Demographics
NPI:1366749467
Name:STONEHENGE DENTAL CLINIC, LLC
Entity type:Organization
Organization Name:STONEHENGE DENTAL CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:BARTLETT
Authorized Official - Suffix:SR
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-745-7777
Mailing Address - Street 1:12331 E CORNELL AVE
Mailing Address - Street 2:#20
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-3323
Mailing Address - Country:US
Mailing Address - Phone:303-745-7777
Mailing Address - Fax:303-755-9014
Practice Address - Street 1:12331 E CORNELL AVE
Practice Address - Street 2:#20
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-3323
Practice Address - Country:US
Practice Address - Phone:303-745-7777
Practice Address - Fax:303-755-9014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-25
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO35361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02035368Medicaid