Healthcare Provider Details

I. General information

NPI: 1053727024
Provider Name (Legal Business Name): MCCOMBS PERIODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2014
Last Update Date: 07/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13335 VOYAGER PKWY SUITE 130
COLORADO SPRINGS CO
80921-7657
US

IV. Provider business mailing address

13335 VOYAGER PKWY SUITE 130
COLORADO SPRINGS CO
80921-7657
US

V. Phone/Fax

Practice location:
  • Phone: 719-368-0950
  • Fax:
Mailing address:
  • Phone: 719-368-0950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDEN.00202187
License Number StateCO

VIII. Authorized Official

Name: JOSEPH K MCCOMBS
Title or Position: DOCTOR
Credential:
Phone: 719-368-0950