Provider Demographics
NPI:1760708176
Name:CLARISA MANTANONA FAMILY DENTISTRY, P.C.
Entity Type:Organization
Organization Name:CLARISA MANTANONA FAMILY DENTISTRY, P.C.
Other - Org Name:PEREGRINE FAMILY DENTISTRY, P.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:D.D.S./PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARISA
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:MANTANONA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-314-2088
Mailing Address - Street 1:1920 VINDICATOR DR
Mailing Address - Street 2:SUITE 211
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-3624
Mailing Address - Country:US
Mailing Address - Phone:719-314-2088
Mailing Address - Fax:719-314-2089
Practice Address - Street 1:1920 VINDICATOR DR
Practice Address - Street 2:SUITE 211
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-3624
Practice Address - Country:US
Practice Address - Phone:719-314-2088
Practice Address - Fax:719-314-2089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-09
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9025122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty