Healthcare Provider Details

I. General information

NPI: 1366025579
Provider Name (Legal Business Name): COLORADO DENTAL ORTHODONTIST PRACTICE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2021
Last Update Date: 05/05/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3236 CENTENNIAL BLVD
COLORADO SPRINGS CO
80907-4077
US

IV. Provider business mailing address

3236 CENTENNIAL BLVD
COLORADO SPRINGS CO
80907-4077
US

V. Phone/Fax

Practice location:
  • Phone: 719-355-2700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE JOHNSON
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 509-315-8338