Provider Demographics
NPI:1447610324
Name:MADJAR, CONSTANCE
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:
Last Name:MADJAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10917 HIDDEN PRAIRIE PKWY
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-7263
Mailing Address - Country:US
Mailing Address - Phone:719-565-7388
Mailing Address - Fax:
Practice Address - Street 1:721 N CASCADE AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-3211
Practice Address - Country:US
Practice Address - Phone:719-633-3366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-04
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CO203122122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program