Provider Demographics
NPI:1952054504
Name:MY LOCAL COLORADO DENTAL PRACTICE, LLC
Entity Type:Organization
Organization Name:MY LOCAL COLORADO DENTAL PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RCM ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSTELAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-372-5605
Mailing Address - Street 1:6110 BARNES RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80922-2600
Mailing Address - Country:US
Mailing Address - Phone:719-266-2717
Mailing Address - Fax:719-213-2311
Practice Address - Street 1:4301 E AMHERST AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80222-6790
Practice Address - Country:US
Practice Address - Phone:303-758-5858
Practice Address - Fax:719-213-2311
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MY LOCAL COLORADO DENTAL PRACTICE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty