Healthcare Provider Details

I. General information

NPI: 1669977427
Provider Name (Legal Business Name): A COUNTRY DENTIST, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 03/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 W 9TH AVE
FORT MORGAN CO
80701-2011
US

IV. Provider business mailing address

107 W 9TH AVE
FORT MORGAN CO
80701-2011
US

V. Phone/Fax

Practice location:
  • Phone: 970-867-2502
  • Fax: 970-867-3795
Mailing address:
  • Phone: 970-867-2502
  • Fax: 970-867-3795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number106313
License Number StateCO

VIII. Authorized Official

Name: DR. PASCO W SCARPELLA
Title or Position: MANAGER
Credential: DDS
Phone: 303-335-8160