Provider Demographics
NPI:1407279607
Name:PRAIRIE VISTA FAMILY DENTAL
Entity Type:Organization
Organization Name:PRAIRIE VISTA FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PASCO
Authorized Official - Middle Name:W
Authorized Official - Last Name:SCARPELLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-335-8160
Mailing Address - Street 1:235 W FLETCHER ST
Mailing Address - Street 2:
Mailing Address - City:HAXTUN
Mailing Address - State:CO
Mailing Address - Zip Code:80731-2737
Mailing Address - Country:US
Mailing Address - Phone:303-335-8160
Mailing Address - Fax:
Practice Address - Street 1:235 W FLETCHER ST
Practice Address - Street 2:
Practice Address - City:HAXTUN
Practice Address - State:CO
Practice Address - Zip Code:80731-2737
Practice Address - Country:US
Practice Address - Phone:303-335-8160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-24
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO106313122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty