Provider Demographics
NPI:1306363429
Name:WINDSOR FAMILY DENTISTRY PRACTICE, LLC
Entity Type:Organization
Organization Name:WINDSOR FAMILY DENTISTRY PRACTICE, LLC
Other - Org Name:WINDSOR FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:N
Authorized Official - Last Name:FREDERICK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-686-1186
Mailing Address - Street 1:6020 N CAREFREE CIR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80922-2402
Mailing Address - Country:US
Mailing Address - Phone:719-266-2717
Mailing Address - Fax:
Practice Address - Street 1:1160 W ASH ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-4666
Practice Address - Country:US
Practice Address - Phone:970-686-1186
Practice Address - Fax:888-790-7062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-29
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO101151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty