Provider Demographics
NPI:1215034939
Name:PRUETT, NICOLAS ROGER (DDS)
Entity Type:Individual
Prefix:MR
First Name:NICOLAS
Middle Name:ROGER
Last Name:PRUETT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:719-576-5566
Mailing Address - Fax:719-576-1100
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:719-576-1100
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8913122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO193616OtherBLUE CROSS VIRGINIA
CO886687OtherUNITED CONCORDIA PROVIDER
CO193616OtherBLUE CROSS VIRGINIA