Provider Demographics
NPI:1477005494
Name:PREFERRED DENTAL
Entity Type:Organization
Organization Name:PREFERRED DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHANAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BANNON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-422-9687
Mailing Address - Street 1:5752 PALMER PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80915-1511
Mailing Address - Country:US
Mailing Address - Phone:719-422-9687
Mailing Address - Fax:
Practice Address - Street 1:5752 PALMER PARK BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80915-1511
Practice Address - Country:US
Practice Address - Phone:719-422-9687
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00202572122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty