Provider Demographics
NPI:1497749386
Name:PAGOSA DENTAL PC
Entity Type:Organization
Organization Name:PAGOSA DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:THORNELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-731-6600
Mailing Address - Street 1:189 TALISMAN DR
Mailing Address - Street 2:SUITE E
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-7916
Mailing Address - Country:US
Mailing Address - Phone:970-731-6600
Mailing Address - Fax:970-731-6604
Practice Address - Street 1:189 TALISMAN DR
Practice Address - Street 2:SUITE E
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147-7916
Practice Address - Country:US
Practice Address - Phone:970-731-6600
Practice Address - Fax:970-731-6604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty