MEDICARE: PREFERRED DENTAL

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	00202572	CO

General Provider Information

NPI Number	:	1477005494
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREFERRED DENTAL

Provider Business Mailing Address
First Line	:	5752 PALMER PARK BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80915-1511
Country	:	US
Telephone Number	:	719-422-9687
Fax Number	:

Provider Business Practice Location Address
First Line	:	5752 PALMER PARK BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80915-1511
Country	:	US
Telephone Number	:	719-422-9687
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. NATHANAEL BANNON
Credential	:	D.D.S
Telephone Number	:	719-422-9687

Provider Enumeration Date	:	10/25/2016
Last Update Date	:	10/25/2016

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Directions to “PREFERRED DENTAL ” Practice Location

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