Provider Demographics
NPI:1669846838
Name:MAIN STREET DENTAL LLC
Entity Type:Organization
Organization Name:MAIN STREET DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:BEUS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:719-275-3255
Mailing Address - Street 1:330 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-3732
Mailing Address - Country:US
Mailing Address - Phone:719-275-3255
Mailing Address - Fax:
Practice Address - Street 1:330 MAIN ST
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-3732
Practice Address - Country:US
Practice Address - Phone:719-275-3255
Practice Address - Fax:719-275-3863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-25
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty