Healthcare Provider Details

I. General information

NPI: 1497382303
Provider Name (Legal Business Name): PUEBLO FAMILY DENTISTRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 03/23/2020
Certification Date: 03/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N GRAND AVENUE SUITE B
PUEBLO CO
81003
US

IV. Provider business mailing address

2810 S. ACADEMY BLVD. SUITE# 130
COLORADO SPRINGS CO
80916
US

V. Phone/Fax

Practice location:
  • Phone: 719-210-4097
  • Fax:
Mailing address:
  • Phone: 719-418-2456
  • Fax: 719-247-8925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. SOMI M LIM
Title or Position: DENTIST/OWNER
Credential: DDS
Phone: 719-418-2456