Provider Demographics
NPI:1801286919
Name:BROADMOOR LAKE DENTAL
Entity type:Organization
Organization Name:BROADMOOR LAKE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN NESS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:719-375-5201
Mailing Address - Street 1:155 LAKE AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-3717
Mailing Address - Country:US
Mailing Address - Phone:719-375-5201
Mailing Address - Fax:844-656-9696
Practice Address - Street 1:155 LAKE AVE STE 201
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3717
Practice Address - Country:US
Practice Address - Phone:719-375-5201
Practice Address - Fax:844-656-9696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-27
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO104909122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty