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General NPI Number Information
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NPI Number | 1760832885
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Entity Type | Organization
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Legal Business Name | IRBY DENTAL COTTAGE
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Dates
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Enumeration Date | 06/20/2016
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Last Update Date | 08/03/2016
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Provider Practice Location Address
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Address Line | 2099 WEST ST # 50 SUITE 180
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City | PUEBLO
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State | CO
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Zip | 81008
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Country | US
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Telephone | 719-543-8808
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Fax | 719-543-8808
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Provider Business Mailing Address
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Address Line | 2012 COMANCHE RD
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City | PUEBLO
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State | CO
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Zip | 81001-1405
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Country | US
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Telephone | 719-543-8808
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Fax | 719-543-8808
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Authorized Official
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Title or Position | OWNER
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Name | MS. PEGGY JO IRBY
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Credential | RDH
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Telephone | 719-543-8808
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | 903535
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License Number State | CO
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