Provider Demographics
NPI:1790140010
Name:DENTERUS DENTAL LAB
Entity Type:Organization
Organization Name:DENTERUS DENTAL LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:BULL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-301-5300
Mailing Address - Street 1:3208 N ACADEMY BLVD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5161
Mailing Address - Country:US
Mailing Address - Phone:719-301-5300
Mailing Address - Fax:719-301-5303
Practice Address - Street 1:3208 N ACADEMY BLVD
Practice Address - Street 2:SUITE 140
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-5161
Practice Address - Country:US
Practice Address - Phone:719-301-5300
Practice Address - Fax:719-301-5303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-31
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00201875122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty