Provider Demographics
NPI:1710360144
Name:CORTEZ DENTAL
Entity Type:Organization
Organization Name:CORTEZ DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:HASSEL
Authorized Official - Last Name:PACK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:970-565-9569
Mailing Address - Street 1:43 W MONTEZUMA AVE
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-2743
Mailing Address - Country:US
Mailing Address - Phone:970-565-9569
Mailing Address - Fax:
Practice Address - Street 1:43 W MONTEZUMA AVE
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-2743
Practice Address - Country:US
Practice Address - Phone:970-565-9569
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-02
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10266302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization