Provider Demographics
NPI:1417377938
Name:LOREN SITES DDS PLLC
Entity Type:Organization
Organization Name:LOREN SITES DDS PLLC
Other - Org Name:PUEBLO DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOREN
Authorized Official - Middle Name:
Authorized Official - Last Name:SITES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-543-2271
Mailing Address - Street 1:4104 OUTLOOK BLVD
Mailing Address - Street 2:SUITE 138
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1670
Mailing Address - Country:US
Mailing Address - Phone:719-543-2271
Mailing Address - Fax:719-543-0972
Practice Address - Street 1:4104 OUTLOOK BLVD
Practice Address - Street 2:SUITE 138
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1670
Practice Address - Country:US
Practice Address - Phone:719-543-2271
Practice Address - Fax:719-543-0972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9979261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO85301035Medicaid