Provider Demographics
NPI:1043211667
Name:STRASBURG DENTAL GROUP
Entity Type:Organization
Organization Name:STRASBURG DENTAL GROUP
Other - Org Name:LIMON DENTAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TABATHA
Authorized Official - Middle Name:C
Authorized Official - Last Name:NORTHUP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-775-0300
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:LIMON
Mailing Address - State:CO
Mailing Address - Zip Code:80828-0160
Mailing Address - Country:US
Mailing Address - Phone:719-775-0300
Mailing Address - Fax:719-775-0302
Practice Address - Street 1:820 1ST ST
Practice Address - Street 2:
Practice Address - City:LIMON
Practice Address - State:CO
Practice Address - Zip Code:80828
Practice Address - Country:US
Practice Address - Phone:719-775-0300
Practice Address - Fax:719-775-0302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO89501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO90079329Medicaid