Healthcare Provider Details

I. General information

NPI: 1285305557
Provider Name (Legal Business Name): COURTNEY CONNELL RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2021
Last Update Date: 09/25/2021
Certification Date: 09/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9240 EXPLORER DR STE 110
COLORADO SPRINGS CO
80920-5004
US

IV. Provider business mailing address

17160 GOSHAWK RD E
COLORADO SPRINGS CO
80908-1628
US

V. Phone/Fax

Practice location:
  • Phone: 719-599-0110
  • Fax:
Mailing address:
  • Phone: 719-685-6852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH000906365
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: