Healthcare Provider Details

I. General information

NPI: 1497103691
Provider Name (Legal Business Name): ICONIC DENTAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2016
Last Update Date: 05/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 MAIN ST
WALSENBURG CO
81089-2136
US

IV. Provider business mailing address

624 MAIN ST
WALSENBURG CO
81089-2136
US

V. Phone/Fax

Practice location:
  • Phone: 719-695-1004
  • Fax: 719-695-1006
Mailing address:
  • Phone: 719-695-1004
  • Fax: 719-695-1006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: TACI COOPER
Title or Position: OFFICE MANAGER
Credential:
Phone: 719-241-3140