Provider Demographics
NPI:1033701313
Name:PROFESSIONAL DENTAL CARE OF SOUTHERN COLORADO I PLLC
Entity Type:Organization
Organization Name:PROFESSIONAL DENTAL CARE OF SOUTHERN COLORADO I PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CARY
Authorized Official - Middle Name:
Authorized Official - Last Name:LACOUTURE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-521-5701
Mailing Address - Street 1:10233 S PARKER RD STE 107
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-9314
Mailing Address - Country:US
Mailing Address - Phone:303-521-5701
Mailing Address - Fax:
Practice Address - Street 1:123 W 2ND ST
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-6201
Practice Address - Country:US
Practice Address - Phone:575-268-0007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSUN HEALTH, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-02-08
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental