Healthcare Provider Details

I. General information

NPI: 1669464632
Provider Name (Legal Business Name): EDWARD A SOUZA D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3466 BRIARGATE BLVD
COLORADO SPRINGS CO
80920-4168
US

IV. Provider business mailing address

3466 BRIARGATE BLVD
COLORADO SPRINGS CO
80920-4168
US

V. Phone/Fax

Practice location:
  • Phone: 719-260-1600
  • Fax: 719-260-1640
Mailing address:
  • Phone: 719-260-1600
  • Fax: 719-260-1640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number7823
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: