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General NPI Number Information
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NPI Number | 1497103691
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Entity Type | Organization
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Legal Business Name | ICONIC DENTAL INC
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Dates
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Enumeration Date | 05/27/2016
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Last Update Date | 05/27/2016
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Provider Practice Location Address
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Address Line | 624 MAIN ST
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City | WALSENBURG
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State | CO
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Zip | 81089-2136
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Country | US
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Telephone | 719-695-1004
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Fax | 719-695-1006
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Provider Business Mailing Address
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Address Line | 624 MAIN ST
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City | WALSENBURG
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State | CO
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Zip | 81089-2136
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Country | US
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Telephone | 719-695-1004
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Fax | 719-695-1006
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | TACI COOPER
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Credential |
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Telephone | 719-241-3140
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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 |
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License Number State | CO
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