MEDICARE: DORSEY DENTAL CARE, INC.

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	1223G0001X	General Practice Dentistry	5456	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1457453151	OTHER	CO	NPI

General Provider Information

NPI Number	:	1730371485
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DORSEY DENTAL CARE, INC.

Provider Business Mailing Address
First Line	:	491 FOREST EDGE RD
Second Line	:
City	:	WOODLAND PARK
State	:	CO
Zip	:	80863-2499
Country	:	US
Telephone Number	:	719-687-6366
Fax Number	:	719-687-6388

Provider Business Practice Location Address
First Line	:	491 FOREST EDGE RD
Second Line	:
City	:	WOODLAND PARK
State	:	CO
Zip	:	80863-2499
Country	:	US
Telephone Number	:	719-687-6366
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. TERRY DORSEY BALTHAZOR
Credential	:	DDS
Telephone Number	:	719-687-6366

Provider Enumeration Date	:	08/16/2007
Last Update Date	:	08/16/2007

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