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NPI Code Detail

MEDICARE: DEROSE CHILDREN'S DENTAL CLINIC, PC

MEDICARE: DEROSE CHILDREN'S DENTAL CLINIC, 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
11223G0001XGeneral Practice Dentistry

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1699724831
Entity Type Code : Organization
Provider Name (Legal Business Name) : DEROSE CHILDREN'S DENTAL CLINIC, PC
Provider Business Mailing Address
First Line : 201 W 8TH ST
Second Line : SUITE 810
City : PUEBLO
State : CO
Zip : 81003-3038
Country : US
Telephone Number : 719-562-4447
Fax Number :
Provider Business Practice Location Address
First Line : 1022 LIBERTY LN
Second Line :
City : PUEBLO
State : CO
Zip : 81001-2039
Country : US
Telephone Number : 719-545-5775
Fax Number :
Authorized Official
Title or Position : DIRECTOR, LICENSING & CREDENTIALING
Name : MS. TRUDY WILLIAMS
Credential :
Telephone Number : 615-750-0342
Provider Enumeration Date : 05/07/2006
Last Update Date : 05/17/2010

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