MEDICARE: CO SPECIALTY DENTAL SERVICES PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1003558479
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CO SPECIALTY DENTAL SERVICES PLLC

Provider Business Mailing Address
First Line	:	1610 54TH AVE N STE 205
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37209-1442
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	501 S TEJON ST STE 200
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-3944
Country	:	US
Telephone Number	:	719-596-3113
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF PROVIDER RELATIONS
Name	:	CHARLOTTE DASCH
Credential	:
Telephone Number	:	504-638-0303

Provider Enumeration Date	:	04/07/2022
Last Update Date	:	04/07/2022

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