Provider Demographics
NPI:1558590596
Name:DOWN TO EARTH DENTAL
Entity Type:Organization
Organization Name:DOWN TO EARTH DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR.
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHILDRESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-546-0404
Mailing Address - Street 1:1407 W 29TH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1269
Mailing Address - Country:US
Mailing Address - Phone:719-546-0404
Mailing Address - Fax:719-546-0408
Practice Address - Street 1:1407 W 29TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1269
Practice Address - Country:US
Practice Address - Phone:719-546-0404
Practice Address - Fax:719-546-0408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-13
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1223G0001X
CO3009124Q00000X, 124Q00000X
CO60421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty