Healthcare Provider Details

I. General information

NPI: 1659702769
Provider Name (Legal Business Name): SOUTH SPRINGS DENTAL PROFESSIONAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2013
Last Update Date: 11/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6514 S ACADEMY BLVD
COLORADO SPRINGS CO
80906-8614
US

IV. Provider business mailing address

6514 S ACADEMY BLVD
COLORADO SPRINGS CO
80906-8614
US

V. Phone/Fax

Practice location:
  • Phone: 719-494-0718
  • Fax:
Mailing address:
  • Phone: 719-494-0718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number10397
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number10397
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number10397
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number10397
License Number StateCO
# 5
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10397
License Number StateCO

VIII. Authorized Official

Name: DR. DOUGLAS PEAK
Title or Position: OWNER/DENTIST
Credential:
Phone: 719-494-0718