Provider Demographics
NPI:1164182242
Name:DENTISTS OF BROADMOOR, LLP
Entity Type:Organization
Organization Name:DENTISTS OF BROADMOOR, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANICA
Authorized Official - Middle Name:J
Authorized Official - Last Name:GILLETTE-BACKSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-249-8775
Mailing Address - Street 1:PO BOX 920050
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75392-0050
Mailing Address - Country:US
Mailing Address - Phone:714-845-8890
Mailing Address - Fax:
Practice Address - Street 1:160 EAST CHEYENNE ROAD
Practice Address - Street 2:SUITE 120
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906
Practice Address - Country:US
Practice Address - Phone:719-249-8775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-30
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty