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General NPI Number Information
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NPI Number | 1164765434
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Entity Type | Organization
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Legal Business Name | HOUSE FAMILY DENTAL PC
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Dates
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Enumeration Date | 04/04/2013
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Last Update Date | 04/04/2013
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Provider Practice Location Address
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Address Line | 1227 S 9TH ST
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City | CANON CITY
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State | CO
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Zip | 81212-4211
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Country | US
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Telephone | 719-924-8623
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Fax |
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Provider Business Mailing Address
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Address Line | 1227 S 9TH ST
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City | CANON CITY
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State | CO
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Zip | 81212-4211
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARK HOUSE
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Credential |
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Telephone | 719-924-8623
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 106275
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License Number State | CO
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