Provider Demographics
NPI:1851476089
Name:MISNER, REBECCA SUZANNE (DMD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:SUZANNE
Last Name:MISNER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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 1:15121 E MISSISSIPPI AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-3746
Practice Address - Country:US
Practice Address - Phone:303-802-1022
Practice Address - Fax:303-802-1023
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS61146122300000X
WADE60310664122300000X
NMDD3822122400000X
CODEN00009208122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA185147089Medicaid
CO1851476089Medicaid
NM85752011Medicaid
KS20113080AMedicaid