Provider Demographics
NPI:1861663668
Name:MY DENTIST INC.
Entity type:Organization
Organization Name:MY DENTIST INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:KRAINIK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-255-4855
Mailing Address - Street 1:3955 E 120TH AVE STE B
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80233-2075
Mailing Address - Country:US
Mailing Address - Phone:303-255-4855
Mailing Address - Fax:303-339-7912
Practice Address - Street 1:3955 E 120TH AVE STE B
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80233-2075
Practice Address - Country:US
Practice Address - Phone:303-255-4855
Practice Address - Fax:303-339-7912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10-49001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV4947TOtherSTATE LICSENCE