Healthcare Provider Details

I. General information

NPI: 1518881598
Provider Name (Legal Business Name): ELENA GRACE CANTWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COCHRANE CIR UNIT MEDDAC
FORT CARSON CO
80913-4604
US

IV. Provider business mailing address

2213 W BIJOU ST
COLORADO SPRINGS CO
80904-3443
US

V. Phone/Fax

Practice location:
  • Phone: 719-526-7000
  • Fax:
Mailing address:
  • Phone: 434-218-9788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401420036
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: