Provider Demographics
NPI:1013245422
Name:SOUTHGLENN ENDODONTICS
Entity Type:Organization
Organization Name:SOUTHGLENN ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SONIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLEGO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:303-797-3636
Mailing Address - Street 1:6650 S VINE ST STE 200
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80121-2735
Mailing Address - Country:US
Mailing Address - Phone:303-797-3636
Mailing Address - Fax:303-993-2048
Practice Address - Street 1:6650 S VINE ST
Practice Address - Street 2:STE 200
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80121-2735
Practice Address - Country:US
Practice Address - Phone:303-797-3636
Practice Address - Fax:303-993-2048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-23
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO92381223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty