Healthcare Provider Details

I. General information

NPI: 1366931024
Provider Name (Legal Business Name): MINERS FAMILY DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 SNOWDEN STE. 4B
SILVERTON CO
81433
US

IV. Provider business mailing address

PO BOX 448
BLANCO NM
87412-0448
US

V. Phone/Fax

Practice location:
  • Phone: 505-634-1501
  • Fax:
Mailing address:
  • Phone: 505-634-1505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDEN.00203360
License Number StateCO

VIII. Authorized Official

Name: MR. DAVID SHRUM
Title or Position: OWNER
Credential: PHD
Phone: 505-634-1501