MEDICARE: CHEYENNE MOUNTAIN CHILDREN'S DENTISTRY PC

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	1223P0221X	Pediatric Dentistry	7055	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000789815	OTHER	CO	UNITED CONCORIDA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578725743
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHEYENNE MOUNTAIN CHILDREN'S DENTISTRY PC

Provider Business Mailing Address
First Line	:	6514 S ACADEMY BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906
Country	:	US
Telephone Number	:	719-442-1960
Fax Number	:

Provider Business Practice Location Address
First Line	:	6514 S ACADEMY BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-8614
Country	:	US
Telephone Number	:	719-442-1960
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	MICHAEL J. PURCELL
Credential	:	DDS
Telephone Number	:	719-442-1960

Provider Enumeration Date	:	06/30/2008
Last Update Date	:	06/30/2008

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