Provider Demographics
NPI:1740594043
Name:BROADMOOR VALLEY DENTAL SERVICES, P.C.
Entity Type:Organization
Organization Name:BROADMOOR VALLEY DENTAL SERVICES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OLIVER
Authorized Official - Middle Name:MORITZ
Authorized Official - Last Name:SPAETH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-632-7636
Mailing Address - Street 1:2965 BROADMOOR VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-4407
Mailing Address - Country:US
Mailing Address - Phone:719-632-7636
Mailing Address - Fax:719-632-5134
Practice Address - Street 1:2965 BROADMOOR VALLEY RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-4407
Practice Address - Country:US
Practice Address - Phone:719-632-7636
Practice Address - Fax:719-632-5134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-29
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO92951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty