Healthcare Provider Details

I. General information

NPI: 1336786250
Provider Name (Legal Business Name): IMAGINE KIDS DENTISTRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2019
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6620 CAMDEN BLVD
FOUNTAIN CO
80817-2505
US

IV. Provider business mailing address

5467 PADDINGTON CREEK PL
COLORADO SPRINGS CO
80924-2083
US

V. Phone/Fax

Practice location:
  • Phone: 719-722-4999
  • Fax:
Mailing address:
  • Phone: 719-722-4999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER JOHNSON
Title or Position: OWNER/PEDIATRIC DENTIST
Credential: DDS
Phone: 719-722-4999