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General NPI Number Information
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NPI Number | 1003776097
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Entity Type | Organization
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Legal Business Name | CANON KIDS DENTAL & BRACES, PC
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Dates
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Enumeration Date | 11/13/2025
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Last Update Date | 11/13/2025
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Provider Practice Location Address
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Address Line | 1201 ROYAL GORGE BLVD
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City | CANON CITY
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State | CO
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Zip | 81212-3835
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Country | US
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Telephone | 719-285-0994
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Fax | 719-285-0996
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Provider Business Mailing Address
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Address Line | 2041 PEPPER LN
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City | PUEBLO
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State | CO
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Zip | 81005-3276
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Country | US
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Telephone | 719-285-0994
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Fax | 719-285-0996
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Authorized Official
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Title or Position | DIRECTOR OF RCM
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Name | ENJOLI GUILLORY
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Credential |
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Telephone | 719-464-0753
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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