Provider Demographics
NPI:1881003002
Name:MINERAL COUNTY DENTAL CLINIC
Entity Type:Organization
Organization Name:MINERAL COUNTY DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNTY COMMISSIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:LAMB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-658-2331
Mailing Address - Street 1:P.O. BOX 57
Mailing Address - Street 2:802 RIO GRANDE AVE
Mailing Address - City:CREEDE
Mailing Address - State:CO
Mailing Address - Zip Code:81130
Mailing Address - Country:US
Mailing Address - Phone:719-658-0322
Mailing Address - Fax:719-658-0322
Practice Address - Street 1:802 RIO GRANDE AVE
Practice Address - Street 2:
Practice Address - City:CREEDE
Practice Address - State:CO
Practice Address - Zip Code:81130
Practice Address - Country:US
Practice Address - Phone:719-658-0322
Practice Address - Fax:719-658-0322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-13
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental