Provider Demographics
NPI:1972656403
Name:BLUE MESA DENTAL
Entity Type:Organization
Organization Name:BLUE MESA DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-489-9800
Mailing Address - Street 1:8100 S QUEBEC ST
Mailing Address - Street 2:ST A 15
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80112
Mailing Address - Country:US
Mailing Address - Phone:720-489-9800
Mailing Address - Fax:720-489-9813
Practice Address - Street 1:8100 S QUEBEC ST
Practice Address - Street 2:ST A 15
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80112
Practice Address - Country:US
Practice Address - Phone:720-489-9800
Practice Address - Fax:720-489-9813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9054122300000X
CO6619122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty