Healthcare Provider Details

I. General information

NPI: 1649390220
Provider Name (Legal Business Name): WESTERN DENTAL GROUP OF ACADEMY BLVD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 N ACADEMY BLVD SUITE 205
COLORADO SPRINGS CO
80909-3325
US

IV. Provider business mailing address

1304 N ACADEMY BLVD SUITE 205
COLORADO SPRINGS CO
80909-3325
US

V. Phone/Fax

Practice location:
  • Phone: 719-596-8440
  • Fax: 719-572-8934
Mailing address:
  • Phone: 719-596-8440
  • Fax: 719-572-8934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number7181
License Number StateCO

VIII. Authorized Official

Name: DR. LEOPOLDO RODRIGUEZ
Title or Position: OWNER
Credential: D.D.S.
Phone: 719-596-3939