Provider Demographics
NPI:1811275670
Name:MISNER DENTAL CORP
Entity type:Organization
Organization Name:MISNER DENTAL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:
Authorized Official - Last Name:URBANOZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-323-2362
Mailing Address - Street 1:2221 E BIJOU ST STE 100
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-8009
Mailing Address - Country:US
Mailing Address - Phone:818-335-2100
Mailing Address - Fax:
Practice Address - Street 1:2621 ZOE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4131
Practice Address - Country:US
Practice Address - Phone:818-335-2100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-28
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA510441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty