Provider Demographics
NPI:1972871051
Name:EAGLE FAMILY DENTISTRY
Entity Type:Organization
Organization Name:EAGLE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:COLLIS
Authorized Official - Last Name:BEAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-328-5268
Mailing Address - Street 1:PO BOX 5499
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:CO
Mailing Address - Zip Code:81631-5499
Mailing Address - Country:US
Mailing Address - Phone:970-328-5268
Mailing Address - Fax:970-328-5267
Practice Address - Street 1:1185 CAPITOL ST
Practice Address - Street 2:SUITE 104
Practice Address - City:EAGLE
Practice Address - State:CO
Practice Address - Zip Code:81631-5000
Practice Address - Country:US
Practice Address - Phone:970-328-5268
Practice Address - Fax:970-328-5267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-05
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO96771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1225288129OtherINDIVIDUAL NPI