Provider Demographics
NPI:1518747765
Name:ELITE DENTAL GROUP CANON CITY INC
Entity Type:Organization
Organization Name:ELITE DENTAL GROUP CANON CITY INC
Other - Org Name:ELITE DENTAL GROUP CANON CITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KYU
Authorized Official - Middle Name:HYUK
Authorized Official - Last Name:JUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-275-5933
Mailing Address - Street 1:1215 N 15TH ST
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-4620
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1215 N 15TH ST
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-4620
Practice Address - Country:US
Practice Address - Phone:719-275-5933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-04
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1396261251Medicaid