Provider Demographics
NPI:1619405396
Name:ORAL SURGERY SPECIALISTS OF PUEBLO, PLLC
Entity Type:Organization
Organization Name:ORAL SURGERY SPECIALISTS OF PUEBLO, PLLC
Other - Org Name:ORAL SURGERY SPECIALISTS OF PUEBLO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:E
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-597-4060
Mailing Address - Street 1:3100 N ACADEMY BLVD STE 213
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5332
Mailing Address - Country:US
Mailing Address - Phone:719-597-4060
Mailing Address - Fax:719-574-2140
Practice Address - Street 1:3691 PARKER BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2278
Practice Address - Country:US
Practice Address - Phone:719-212-0777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-25
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty