Healthcare Provider Details

I. General information

NPI: 1184637811
Provider Name (Legal Business Name): MICHAEL DEAN KOFFORD DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 09/12/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1694 E CHEYENNE MOUNTAIN BLVD
COLORADO SPRINGS CO
80906-4050
US

IV. Provider business mailing address

5152 S NEPAL WAY
CENTENNIAL CO
80015-6402
US

V. Phone/Fax

Practice location:
  • Phone: 719-538-4671
  • Fax:
Mailing address:
  • Phone: 303-997-6539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number8999
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: