Provider Demographics
NPI:1053768184
Name:MILOT PEDIATRIC DENTISTRY, LLC
Entity type:Organization
Organization Name:MILOT PEDIATRIC DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:MILOT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-719-3700
Mailing Address - Street 1:2851 SHADOW LAKE RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-8970
Mailing Address - Country:US
Mailing Address - Phone:503-719-3700
Mailing Address - Fax:
Practice Address - Street 1:2055 KEN PRATT BLVD
Practice Address - Street 2:UNIT B
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6554
Practice Address - Country:US
Practice Address - Phone:503-719-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-18
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO94091223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO53451767Medicaid