Provider Demographics
NPI:1740511765
Name:HOUSE FAMILY DENTAL PC
Entity type:Organization
Organization Name:HOUSE FAMILY DENTAL PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:T
Authorized Official - Last Name:HOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:719-924-8623
Mailing Address - Street 1:318 S ORCHARD SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-6149
Mailing Address - Country:US
Mailing Address - Phone:719-924-8623
Mailing Address - Fax:719-924-9556
Practice Address - Street 1:318 S ORCHARD SPRINGS DR
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-6149
Practice Address - Country:US
Practice Address - Phone:719-924-8623
Practice Address - Fax:719-924-9556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-15
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO106275122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty