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General NPI Number Information
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NPI Number | 1881747319
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Entity Type | Organization
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Legal Business Name | BLUE MESA DENTISTRY AT SOUTHGLENN
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Dates
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Enumeration Date | 01/19/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2001 E EASTER AVE #200
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City | CENTENNIAL
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State | CO
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Zip | 80122
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Country | US
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Telephone | 303-703-4544
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Fax | 303-703-3610
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Provider Business Mailing Address
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Address Line | 2001 E EASTER AVE #200
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City | CENTENNIAL
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State | CO
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Zip | 80122
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Country | US
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Telephone | 303-703-4544
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Fax | 303-703-3610
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MARISSA ANNE NICHOLSON
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Credential |
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Telephone | 303-703-4544
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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 | 6619
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 6372
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License Number State | CO
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