MEDICARE: SUMMIT DENTAL SPA, LLC

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	124Q00000X	Dental Hygienist

General Provider Information

NPI Number	:	1518821511
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUMMIT DENTAL SPA, LLC

Provider Business Mailing Address
First Line	:	190 TALISMAN DR UNIT D4
Second Line	:
City	:	PAGOSA SPRINGS
State	:	CO
Zip	:	81147-9171
Country	:	US
Telephone Number	:	970-585-4424
Fax Number	:

Provider Business Practice Location Address
First Line	:	190 TALISMAN DR UNIT D4
Second Line	:
City	:	PAGOSA SPRINGS
State	:	CO
Zip	:	81147-9171
Country	:	US
Telephone Number	:	970-585-4424
Fax Number	:

Authorized Official
Title or Position	:	OWNER, REGISTERED DENTAL HYGIENIST
Name	:	DOROTHY HORN
Credential	:	RDH
Telephone Number	:	970-585-4424

Provider Enumeration Date	:	12/13/2025
Last Update Date	:	12/13/2025

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Directions to “SUMMIT DENTAL SPA, LLC ” Practice Location

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