Provider Demographics
NPI:1790997161
Name:BRIARGATE PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:BRIARGATE PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:SOUZA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:719-260-1600
Mailing Address - Street 1:3466 BRIARGATE BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-4168
Mailing Address - Country:US
Mailing Address - Phone:719-260-1600
Mailing Address - Fax:719-260-1640
Practice Address - Street 1:3466 BRIARGATE BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-4168
Practice Address - Country:US
Practice Address - Phone:719-260-1600
Practice Address - Fax:719-260-1640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7823261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental