Provider Demographics
NPI:1023412095
Name:PRESTIGE DENTAL LLC
Entity type:Organization
Organization Name:PRESTIGE DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:D
Authorized Official - Last Name:SHAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-597-3700
Mailing Address - Street 1:3208 N ACADEMY BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5171
Mailing Address - Country:US
Mailing Address - Phone:719-597-3700
Mailing Address - Fax:719-597-7507
Practice Address - Street 1:3208 N ACADEMY BLVD STE 110
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-5171
Practice Address - Country:US
Practice Address - Phone:719-597-3700
Practice Address - Fax:719-597-7507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-20
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO201875122300000X
CODH000905418124Q00000X
CO7989122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO97401862Medicaid
CO65426061Medicaid
CO38873362Medicaid