Healthcare Provider Details

I. General information

NPI: 1669846838
Provider Name (Legal Business Name): MAIN STREET DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2015
Last Update Date: 02/09/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 MAIN ST
CANON CITY CO
81212-3732
US

IV. Provider business mailing address

330 MAIN ST
CANON CITY CO
81212-3732
US

V. Phone/Fax

Practice location:
  • Phone: 719-275-3255
  • Fax: 719-275-3863
Mailing address:
  • Phone: 719-275-3255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: JACOB BEUS
Title or Position: OWNER
Credential: DMD
Phone: 719-275-3255