Provider Demographics
NPI:1366896318
Name:PDC LOS NINOS LLC
Entity type:Organization
Organization Name:PDC LOS NINOS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KENDALL
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:SKINNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:303-777-5437
Mailing Address - Street 1:2476 N UNIVERSITY PKWY STE 201
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3869
Mailing Address - Country:US
Mailing Address - Phone:801-305-3460
Mailing Address - Fax:801-692-9083
Practice Address - Street 1:1250 S SHERIDAN BLVD
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80232-8022
Practice Address - Country:US
Practice Address - Phone:303-777-5437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-15
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT29241389031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty