Provider Demographics
NPI:1891222402
Name:PUEBLO DENTAL & BRACES
Entity Type:Organization
Organization Name:PUEBLO DENTAL & BRACES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-602-0691
Mailing Address - Street 1:4542 VALLEYBROOK DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80130-6965
Mailing Address - Country:US
Mailing Address - Phone:623-910-5569
Mailing Address - Fax:
Practice Address - Street 1:1345 S PUEBLO BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-1508
Practice Address - Country:US
Practice Address - Phone:623-910-5569
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN 202339122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty