Provider Demographics
NPI:1801406434
Name:SOUTHERN COLORADO DENTAL ANESTHESIOLOGY
Entity Type:Organization
Organization Name:SOUTHERN COLORADO DENTAL ANESTHESIOLOGY
Other - Org Name:SOUTHERN COLORADO DENTAL ANESTHESIA
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST ANESTHESIOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:KELLAN
Authorized Official - Last Name:VILLALON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MPH
Authorized Official - Phone:719-286-0733
Mailing Address - Street 1:1225 N MAIN ST STE 207
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2857
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1225 N MAIN ST STE 207
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2857
Practice Address - Country:US
Practice Address - Phone:719-286-0733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-07
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental