Provider Demographics
NPI:1902213135
Name:JADE DENTAL PROFESSIONALS
Entity Type:Organization
Organization Name:JADE DENTAL PROFESSIONALS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINSTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:L
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-633-0770
Mailing Address - Street 1:703 N TEJON ST STE A
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-1050
Mailing Address - Country:US
Mailing Address - Phone:719-313-8666
Mailing Address - Fax:
Practice Address - Street 1:703 N TEJON ST STE A
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-1050
Practice Address - Country:US
Practice Address - Phone:719-313-8666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO71571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty