Provider Demographics
NPI:1649390220
Name:WESTERN DENTAL GROUP OF ACADEMY BLVD
Entity Type:Organization
Organization Name:WESTERN DENTAL GROUP OF ACADEMY BLVD
Other - Org Name:ACADEMY BLVD ORAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEOPOLDO
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-596-3939
Mailing Address - Street 1:1304 N ACADEMY BLVD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-3325
Mailing Address - Country:US
Mailing Address - Phone:719-596-8440
Mailing Address - Fax:719-572-8934
Practice Address - Street 1:1304 N ACADEMY BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-3325
Practice Address - Country:US
Practice Address - Phone:719-596-8440
Practice Address - Fax:719-572-8934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO71811223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty