Healthcare Provider Details

I. General information

NPI: 1285021543
Provider Name (Legal Business Name): FRONT RANGE PEDIATRIC DENTISTRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2015
Last Update Date: 04/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6160 TUTT BLVD SUITE 140
COLORADO SPRINGS CO
80923-3500
US

IV. Provider business mailing address

6160 TUTT BLVD SUITE 140
COLORADO SPRINGS CO
80923-3500
US

V. Phone/Fax

Practice location:
  • Phone: 719-550-1010
  • Fax: 719-550-1212
Mailing address:
  • Phone: 719-550-1010
  • Fax: 719-550-1212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDEN9841
License Number StateCO

VIII. Authorized Official

Name: DR. DEREK MILLER
Title or Position: OWNER
Credential: DDS
Phone: 719-550-1010