Healthcare Provider Details

I. General information

NPI: 1770679904
Provider Name (Legal Business Name): SARA DEVINE DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 S ACADEMY BLVD
COLORADO SPRINGS CO
80916-2408
US

IV. Provider business mailing address

2440 S ACADEMY BLVD
COLORADO SPRINGS CO
80916-2408
US

V. Phone/Fax

Practice location:
  • Phone: 719-576-1850
  • Fax:
Mailing address:
  • Phone: 719-576-1850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number10130
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberS3-71C
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: