Provider Demographics
NPI:1164103685
Name:ELITE DENTAL GROUP SE CO SPRINGS INC
Entity Type:Organization
Organization Name:ELITE DENTAL GROUP SE CO SPRINGS INC
Other - Org Name:ELITE DENTAL GROUP SE CO SPRINGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KYU
Authorized Official - Middle Name:HYUK
Authorized Official - Last Name:JUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-301-6680
Mailing Address - Street 1:2753 JANITELL RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-4102
Mailing Address - Country:US
Mailing Address - Phone:719-301-6680
Mailing Address - Fax:
Practice Address - Street 1:2753 JANITELL RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-4102
Practice Address - Country:US
Practice Address - Phone:719-301-6680
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-27
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental