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General NPI Number Information
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NPI Number | 1609096999
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Entity Type | Organization
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Legal Business Name | PUEBLO ENDODONTIC ASSO LLC
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Dates
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Enumeration Date | 04/27/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 41 MONTEBELLO SUITE 206
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City | PUEBLO
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State | CO
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Zip | 81001
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Country | US
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Telephone | 719-544-8900
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Fax | 719-545-0700
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Provider Business Mailing Address
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Address Line | PO BOX 9660
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City | PUEBLO
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State | CO
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Zip | 81008-9409
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Country | US
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Telephone | 719-544-8900
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Fax | 719-545-0700
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. REGINALD R WESTPHAL
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Credential | DDS MS
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Telephone | 719-544-8900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | 100988
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License Number State | CO
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