Provider Demographics
NPI:1295037646
Name:BROADMOOR DENTAL, LLC
Entity Type:Organization
Organization Name:BROADMOOR DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLAS
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:PRUETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-576-5566
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO89131223G0001X
CO99661223G0001X
CO99521223G0001X
CO905802124Q00000X
CO905995124Q00000X
CO906138124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Single Specialty