Provider Demographics
NPI:1558806679
Name:SOCO ENDO
Entity Type:Organization
Organization Name:SOCO ENDO
Other - Org Name:SOUTHERN COLORADO ENDODONTICS
Other - Org Type:Other Name
Authorized Official - Title/Position:ENDODONTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:J
Authorized Official - Last Name:BOSS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-301-1131
Mailing Address - Street 1:1275 LAKE PLAZA DRIVE
Mailing Address - Street 2:SUITE #200
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906
Mailing Address - Country:US
Mailing Address - Phone:719-301-1119
Mailing Address - Fax:719-301-1131
Practice Address - Street 1:1275 LAKE PLAZA DRIVE
Practice Address - Street 2:SUITE #200
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906
Practice Address - Country:US
Practice Address - Phone:719-301-1119
Practice Address - Fax:719-301-1131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-28
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty