Provider Demographics
NPI:1578181103
Name:STETTLER KR BROADMOOR PLLC
Entity Type:Organization
Organization Name:STETTLER KR BROADMOOR PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DDS
Authorized Official - Prefix:
Authorized Official - First Name:CORBAN
Authorized Official - Middle Name:
Authorized Official - Last Name:STETTLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-304-1305
Mailing Address - Street 1:4515 BROADMOOR BLUFFS DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-8647
Mailing Address - Country:US
Mailing Address - Phone:719-424-4668
Mailing Address - Fax:719-424-4667
Practice Address - Street 1:4515 BROADMOOR BLUFFS DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-8647
Practice Address - Country:US
Practice Address - Phone:719-424-4668
Practice Address - Fax:719-424-4667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty