Provider Demographics
NPI:1578760302
Name:COLORADO SPRINGS PEDIATRIC DENTISTRY, PC
Entity Type:Organization
Organization Name:COLORADO SPRINGS PEDIATRIC DENTISTRY, PC
Other - Org Name:COLORADO SPRINGS PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CASSIE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:SEARS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-522-0123
Mailing Address - Street 1:9480 BRIAR VILLAGE POINT
Mailing Address - Street 2:SUITE 301
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920
Mailing Address - Country:US
Mailing Address - Phone:719-522-0123
Mailing Address - Fax:719-266-6614
Practice Address - Street 1:9480 BRIAR VILLAGE POINT
Practice Address - Street 2:SUITE 301
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920
Practice Address - Country:US
Practice Address - Phone:719-522-0123
Practice Address - Fax:719-266-6614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO85061223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty