Healthcare Provider Details

I. General information

NPI: 1609096999
Provider Name (Legal Business Name): PUEBLO ENDODONTIC ASSO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 MONTEBELLO SUITE 206
PUEBLO CO
81001
US

IV. Provider business mailing address

PO BOX 9660
PUEBLO CO
81008-9409
US

V. Phone/Fax

Practice location:
  • Phone: 719-544-8900
  • Fax: 719-545-0700
Mailing address:
  • Phone: 719-544-8900
  • Fax: 719-545-0700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number100988
License Number StateCO

VIII. Authorized Official

Name: DR. REGINALD R WESTPHAL
Title or Position: PRESIDENT
Credential: DDS MS
Phone: 719-544-8900