Healthcare Provider Details

I. General information

NPI: 1043963697
Provider Name (Legal Business Name): COLORADO DENTAL SPECIALIST PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2022
Last Update Date: 02/02/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 E AMHERST AVE
DENVER CO
80222-6790
US

IV. Provider business mailing address

6110 BARNES RD
COLORADO SPRINGS CO
80922-2600
US

V. Phone/Fax

Practice location:
  • Phone: 303-758-5858
  • Fax: 719-213-2311
Mailing address:
  • Phone: 719-266-2717
  • Fax: 719-213-2311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: GREGORY KOSTELAC
Title or Position: RCM ANALYST
Credential:
Phone: 719-372-5605