=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578181103
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STETTLER KR BROADMOOR PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2020
-----------------------------------------------------
Last Update Date | 07/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4515 BROADMOOR BLUFFS DR
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80906-8647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-424-4668
-----------------------------------------------------
Fax | 719-424-4667
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4515 BROADMOOR BLUFFS DR
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80906-8647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-424-4668
-----------------------------------------------------
Fax | 719-424-4667
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DDS
-----------------------------------------------------
Name | CORBAN STETTLER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 719-304-1305
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------