Healthcare Provider Details

I. General information

NPI: 1790370617
Provider Name (Legal Business Name): NEHA DC JIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2021
Last Update Date: 06/02/2024
Certification Date: 06/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3630 AUSTIN BLUFFS PKWY
COLORADO SPRINGS CO
80918-6661
US

IV. Provider business mailing address

1670 E CHEYENNE MOUNTAIN BLVD STE F #301
COLORADO SPRINGS CO
80906
US

V. Phone/Fax

Practice location:
  • Phone: 719-304-5400
  • Fax:
Mailing address:
  • Phone: 719-502-9070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN.00205004
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: