Healthcare Provider Details

I. General information

NPI: 1780238311
Provider Name (Legal Business Name): COLORADO DENTAL SPECIALIST PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2019
Last Update Date: 07/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 W ASH ST
WINDSOR CO
80550-4666
US

IV. Provider business mailing address

1160 W ASH ST
WINDSOR CO
80550-4666
US

V. Phone/Fax

Practice location:
  • Phone: 970-686-1186
  • Fax:
Mailing address:
  • Phone: 970-686-1186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MICHELLE JOHNSON
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 509-315-8338