Healthcare Provider Details

I. General information

NPI: 1144745647
Provider Name (Legal Business Name): COMPREHENSIVE DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 UNIVERSITY ST STE 1
TRINIDAD CO
81082-2560
US

IV. Provider business mailing address

417 UNIVERSITY ST STE 1
TRINIDAD CO
81082-2560
US

V. Phone/Fax

Practice location:
  • Phone: 719-846-7387
  • Fax:
Mailing address:
  • Phone: 719-846-7387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number7109
License Number StateCO

VIII. Authorized Official

Name: DR. AMY WILSON
Title or Position: DR.
Credential: DDS
Phone: 719-846-7387