Provider Demographics
NPI:1407180540
Name:LICENSED DENTAL HYGIENE CARE
Entity Type:Organization
Organization Name:LICENSED DENTAL HYGIENE CARE
Other - Org Name:COMMUNITY DENTAL HEALTH, SENIOR MOBILE DENTAL, GRAND AVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:P.
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:VACHA
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:719-310-3315
Mailing Address - Street 1:1436 N. HANCOCK AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903
Mailing Address - Country:US
Mailing Address - Phone:719-338-2195
Mailing Address - Fax:719-207-8110
Practice Address - Street 1:1436 N. HANCOCK AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903
Practice Address - Country:US
Practice Address - Phone:719-338-2195
Practice Address - Fax:719-207-8110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-22
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20071454175251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable