Provider Demographics
NPI:1427360254
Name:AUSTINBLUFFS DENTAL PROF. LLC
Entity Type:Organization
Organization Name:AUSTINBLUFFS DENTAL PROF. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFFER
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-591-1811
Mailing Address - Street 1:3952 N ACADEMY BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5910
Mailing Address - Country:US
Mailing Address - Phone:719-591-1811
Mailing Address - Fax:719-591-2032
Practice Address - Street 1:3952 NORTH ACADEMY
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917
Practice Address - Country:US
Practice Address - Phone:719-591-1811
Practice Address - Fax:719-591-2032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-09
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO98501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty