Provider Demographics
NPI:1659702769
Name:SOUTH SPRINGS DENTAL PROFESSIONAL LLC
Entity Type:Organization
Organization Name:SOUTH SPRINGS DENTAL PROFESSIONAL LLC
Other - Org Name:SOUTH SPRINGS DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:PEAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-494-0718
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:80906-8614
Mailing Address - Country:US
Mailing Address - Phone:719-494-0718
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:719-494-0718
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-29
Last Update Date:2013-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO103971223E0200X, 1223G0001X, 1223P0300X, 1223S0112X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO10397OtherDENTAL