Provider Demographics
NPI:1982758173
Name:EDGAR P POREMBA DDS MSD PC
Entity Type:Organization
Organization Name:EDGAR P POREMBA DDS MSD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:P
Authorized Official - Last Name:POREMBA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MSD
Authorized Official - Phone:719-576-0149
Mailing Address - Street 1:2997 BROADMOOR VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-4405
Mailing Address - Country:US
Mailing Address - Phone:719-576-0149
Mailing Address - Fax:719-579-5373
Practice Address - Street 1:2997 BROADMOOR VALLEY RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPGS
Practice Address - State:CO
Practice Address - Zip Code:80906-4405
Practice Address - Country:US
Practice Address - Phone:719-576-0149
Practice Address - Fax:719-579-5373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1057191223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty