Provider Demographics
NPI:1760864235
Name:PEDIATRIC DENTAL GROUP II, LLC
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL GROUP II, LLC
Other - Org Name:PEDIATRIC DENTAL GROUP II, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:
Authorized Official - Last Name:URBANOZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-323-2362
Mailing Address - Street 1:2221 E BIJOU ST STE 100
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-8009
Mailing Address - Country:US
Mailing Address - Phone:719-576-1850
Mailing Address - Fax:719-955-3470
Practice Address - Street 1:7715 E 91ST ST STE A
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-6060
Practice Address - Country:US
Practice Address - Phone:918-585-3744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-22
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK321223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK3942OtherOK DENTAL LICENSE