MEDICARE: MR. NICOLAS ROGER PRUETT DD.S.

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	122300000X	Dentist	8913	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	193616	OTHER	CO	BLUE CROSS VIRGINIA
2	886687	OTHER	CO	UNITED CONCORDIA PROVIDER

General Provider Information

NPI Number	:	1215034939
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. NICOLAS ROGER PRUETT DD.S.

Provider Business Mailing Address
First Line	:	1930 S. NEVADA AVE
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80905-3407
Country	:	US
Telephone Number	:	719-576-5566
Fax Number	:	719-576-1100

Provider Business Practice Location Address
First Line	:	1930 S. NEVADA AVE
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80905-3407
Country	:	US
Telephone Number	:	719-576-5566
Fax Number	:	719-576-1100

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/17/2006
Last Update Date	:	08/13/2010

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