=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881456333
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORCHARD MESA DENTAL P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2024
-----------------------------------------------------
Last Update Date | 01/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2773 B 1/2 RD STE A
-----------------------------------------------------
City | GRAND JUNCTION
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81503-3036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-257-1103
-----------------------------------------------------
Fax | 970-257-7522
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1422 BLUE CREEK AVE
-----------------------------------------------------
City | MONTROSE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81401-4302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-471-3690
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANDRE CARDOSO
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 801-471-3690
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------