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General NPI Number Information
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NPI Number | 1336786250
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Entity Type | Organization
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Legal Business Name | IMAGINE KIDS DENTISTRY PLLC
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Dates
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Enumeration Date | 12/10/2019
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Last Update Date | 02/12/2020
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Provider Practice Location Address
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Address Line | 6620 CAMDEN BLVD
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City | FOUNTAIN
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State | CO
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Zip | 80817-2505
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Country | US
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Telephone | 719-722-4999
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Fax |
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Provider Business Mailing Address
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Address Line | 5467 PADDINGTON CREEK PL
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City | COLORADO SPRINGS
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State | CO
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Zip | 80924-2083
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Country | US
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Telephone | 719-722-4999
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Fax |
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Authorized Official
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Title or Position | OWNER/PEDIATRIC DENTIST
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Name | CHRISTOPHER JOHNSON
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Credential | DDS
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Telephone | 719-722-4999
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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