Provider Demographics
NPI:1093456857
Name:COLORADO DENTAL PROFESSIONALS, LLC
Entity Type:Organization
Organization Name:COLORADO DENTAL PROFESSIONALS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:HILLARY
Authorized Official - Middle Name:
Authorized Official - Last Name:THULL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8946
Mailing Address - Street 1:1930 S NEVADA AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80905-3407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1930 S NEVADA AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905-3407
Practice Address - Country:US
Practice Address - Phone:719-576-5566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLORADO DENTAL PROFESSIONALS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty