Healthcare Provider Details

I. General information

NPI: 1992063176
Provider Name (Legal Business Name): MONUMENT CHILD DENTAL & ORTHODONTIC SPECIALISTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2012
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 SKY VISTA POINT
COLORADO SPRINGS CO
80921-1400
US

IV. Provider business mailing address

9334 GRAND CORDERA PKWY
COLORADO SPRINGS CO
80924-7000
US

V. Phone/Fax

Practice location:
  • Phone: 719-488-1101
  • Fax: 719-488-1115
Mailing address:
  • Phone: 719-282-6666
  • Fax: 719-203-5477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number9665
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number9665
License Number StateCO

VIII. Authorized Official

Name: DAWN RUSH
Title or Position: BUSINESS MANAGER
Credential:
Phone: 719-282-6666