Provider Demographics
NPI:1366960775
Name:ON-SITE DENTIST, LLC
Entity type:Organization
Organization Name:ON-SITE DENTIST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF DENTISTRY
Authorized Official - Prefix:
Authorized Official - First Name:TYSON
Authorized Official - Middle Name:
Authorized Official - Last Name:PECHEK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-821-2237
Mailing Address - Street 1:PO BOX 3449
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:80155-3449
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10734 E BERRY AVE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80111-3972
Practice Address - Country:US
Practice Address - Phone:719-821-2237
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-06
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO91631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty