Healthcare Provider Details

I. General information

NPI: 1578725743
Provider Name (Legal Business Name): CHEYENNE MOUNTAIN CHILDREN'S DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 06/30/2008
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
US

V. Phone/Fax

Practice location:
  • Phone: 719-442-1960
  • Fax:
Mailing address:
  • Phone: 719-442-1960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number7055
License Number StateCO

VIII. Authorized Official

Name: MICHAEL J. PURCELL
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 719-442-1960