Healthcare Provider Details

I. General information

NPI: 1407279607
Provider Name (Legal Business Name): PRAIRIE VISTA FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2014
Last Update Date: 01/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 W FLETCHER ST
HAXTUN CO
80731-2737
US

IV. Provider business mailing address

235 W FLETCHER ST
HAXTUN CO
80731-2737
US

V. Phone/Fax

Practice location:
  • Phone: 303-335-8160
  • Fax:
Mailing address:
  • Phone: 303-335-8160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number106313
License Number StateCO

VIII. Authorized Official

Name: DR. PASCO W SCARPELLA
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 303-335-8160