Provider Demographics
NPI:1578725743
Name:CHEYENNE MOUNTAIN CHILDREN'S DENTISTRY PC
Entity Type:Organization
Organization Name:CHEYENNE MOUNTAIN CHILDREN'S DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:PURCELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-442-1960
Mailing Address - Street 1:6514 S ACADEMY BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906
Mailing Address - Country:US
Mailing Address - Phone:719-442-1960
Mailing Address - Fax:
Practice Address - Street 1:6514 S ACADEMY BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-8614
Practice Address - Country:US
Practice Address - Phone:719-442-1960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO70551223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO000789815OtherUNITED CONCORIDA
CO0207555Medicaid