Provider Demographics
NPI:1417587858
Name:SOCO SMILES NORTH LLC
Entity Type:Organization
Organization Name:SOCO SMILES NORTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KOFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MSD
Authorized Official - Phone:719-331-2504
Mailing Address - Street 1:4625 ALPGLEN CT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-8213
Mailing Address - Country:US
Mailing Address - Phone:719-331-2504
Mailing Address - Fax:
Practice Address - Street 1:8540 SCARBOROUGH DR STE 250
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7502
Practice Address - Country:US
Practice Address - Phone:719-487-9303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-24
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental