Healthcare Provider Details

I. General information

NPI: 1740751460
Provider Name (Legal Business Name): AUDUBON DENTAL SLEEP SOLUTIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2018
Last Update Date: 12/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2960 N CIRCLE DR STE 105
COLORADO SPRINGS CO
80909-1163
US

IV. Provider business mailing address

2960 N CIRCLE DR STE 105
COLORADO SPRINGS CO
80909-1163
US

V. Phone/Fax

Practice location:
  • Phone: 719-597-6300
  • Fax: 719-597-8266
Mailing address:
  • Phone: 719-597-6300
  • Fax: 719-597-8266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. MYLENE REINICKE
Title or Position: PRESIDENT
Credential: DDS
Phone: 719-597-6300