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General NPI Number Information
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NPI Number | 1740511765
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Entity Type | Organization
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Legal Business Name | HOUSE FAMILY DENTAL PC
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Dates
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Enumeration Date | 01/15/2010
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Last Update Date | 03/01/2016
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Provider Practice Location Address
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Address Line | 318 S ORCHARD SPRINGS DR
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City | PUEBLO WEST
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State | CO
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Zip | 81007-6149
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Country | US
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Telephone | 719-924-8623
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Fax | 719-924-9556
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Provider Business Mailing Address
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Address Line | 318 S ORCHARD SPRINGS DR
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City | PUEBLO WEST
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State | CO
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Zip | 81007-6149
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Country | US
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Telephone | 719-924-8623
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Fax | 719-924-9556
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Authorized Official
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Title or Position | DOCTOR/OWNER
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Name | DR. MARK T HOUSE
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Credential | DMD
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Telephone | 719-924-8623
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 106275
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License Number State | CO
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