Provider Demographics
NPI:1811298664
Name:JADE DENTAL PROFESSIONALS
Entity type:Organization
Organization Name:JADE DENTAL PROFESSIONALS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:L
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-266-9393
Mailing Address - Street 1:6020 ERIN PARK DR STE B
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-3429
Mailing Address - Country:US
Mailing Address - Phone:719-266-9393
Mailing Address - Fax:719-266-9494
Practice Address - Street 1:6020 ERIN PARK DR STE B
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-3429
Practice Address - Country:US
Practice Address - Phone:719-266-9393
Practice Address - Fax:719-266-9494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-10
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO71571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty