Provider Demographics
NPI:1275915142
Name:BEAR CREEK DENTAL
Entity Type:Organization
Organization Name:BEAR CREEK DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:BRYAN
Authorized Official - Last Name:MASTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-633-2828
Mailing Address - Street 1:1430 S 21ST ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80904-4225
Mailing Address - Country:US
Mailing Address - Phone:719-633-2828
Mailing Address - Fax:719-633-7461
Practice Address - Street 1:1430 S 21ST ST
Practice Address - Street 2:SUITE 200
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-4225
Practice Address - Country:US
Practice Address - Phone:719-633-2828
Practice Address - Fax:719-633-7461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-26
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO73001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1992871909OtherINDIVIDUAL NPI