Provider Demographics
NPI:1497382303
Name:PUEBLO FAMILY DENTISTRY PLLC
Entity Type:Organization
Organization Name:PUEBLO FAMILY DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SOMI
Authorized Official - Middle Name:M
Authorized Official - Last Name:LIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-418-2456
Mailing Address - Street 1:2810 S. ACADEMY BLVD.
Mailing Address - Street 2:SUITE# 130
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80916
Mailing Address - Country:US
Mailing Address - Phone:719-418-2456
Mailing Address - Fax:719-247-8925
Practice Address - Street 1:701 N GRAND AVENUE
Practice Address - Street 2:SUITE B
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003
Practice Address - Country:US
Practice Address - Phone:719-210-4097
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-23
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty