Healthcare Provider Details

I. General information

NPI: 1982758173
Provider Name (Legal Business Name): EDGAR P POREMBA DDS MSD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2997 BROADMOOR VALLEY RD
COLORADO SPGS CO
80906-4405
US

IV. Provider business mailing address

2997 BROADMOOR VALLEY RD
COLORADO SPGS CO
80906-4405
US

V. Phone/Fax

Practice location:
  • Phone: 719-576-0149
  • Fax: 719-579-5373
Mailing address:
  • Phone: 719-576-0149
  • Fax: 719-579-5373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number105719
License Number StateCO

VIII. Authorized Official

Name: DR. EDGAR P POREMBA
Title or Position: ORTHODONTIST
Credential: DDS MSD
Phone: 719-576-0149