=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609231968
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENNIS P. DRISCOLL DDS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2015
-----------------------------------------------------
Last Update Date | 06/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 129 KANSAS AVE
-----------------------------------------------------
City | WALSENBRUG
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81089
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-252-1822
-----------------------------------------------------
Fax | 719-676-3306
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8225 LAGO VISTAS BLVD
-----------------------------------------------------
City | COLORADO CITY
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-252-1822
-----------------------------------------------------
Fax | 719-676-3306
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DENNIS P DRISCOLL
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 719-252-1822
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------