MEDICARE: MISNER PROFESSIONAL DENTAL CORP

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	51044	CA

General Provider Information

NPI Number	:	1407926132
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISNER PROFESSIONAL DENTAL CORP

Provider Business Mailing Address
First Line	:	2221 E BIJOU ST STE 100
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-8009
Country	:	US
Telephone Number	:	719-576-1850
Fax Number	:

Provider Business Practice Location Address
First Line	:	514 S ALVARADO ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90057-2904
Country	:	US
Telephone Number	:	213-259-0606
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. REBECCA MISNER
Credential	:	DMD
Telephone Number	:	719-323-2362

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	06/19/2023

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