Provider Demographics
NPI:1568017077
Name:COLORADO DENTAL SPECIALIST PRACTICE, LLC
Entity Type:Organization
Organization Name:COLORADO DENTAL SPECIALIST PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-315-8338
Mailing Address - Street 1:3715 BLOOMINGTON ST UNIT 160
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80922-3207
Mailing Address - Country:US
Mailing Address - Phone:719-599-0665
Mailing Address - Fax:
Practice Address - Street 1:3715 BLOOMINGTON ST UNIT 160
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80922-3207
Practice Address - Country:US
Practice Address - Phone:719-599-0665
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLORADO DENTAL SPECIALIST PRACTICE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-08-02
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty