Healthcare Provider Details

I. General information

NPI: 1336570167
Provider Name (Legal Business Name): MEDICAID DENTAL HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2013
Last Update Date: 12/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2125 E LA SALLE ST
COLORADO SPRINGS CO
80909-2274
US

IV. Provider business mailing address

2604 FLINTRIDGE DR
COLORADO SPRINGS CO
80918-4408
US

V. Phone/Fax

Practice location:
  • Phone: 719-310-3315
  • Fax:
Mailing address:
  • Phone: 719-338-2195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number903783
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number8109
License Number StateCO

VIII. Authorized Official

Name: MICHELLE VACHA
Title or Position: EXECUTIVE DIRECTOR
Credential: RDH
Phone: 719-338-2195