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General NPI Number Information
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NPI Number | 1891222402
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Entity Type | Organization
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Legal Business Name | PUEBLO DENTAL & BRACES
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Dates
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Enumeration Date | 05/12/2017
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Last Update Date | 05/12/2017
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Provider Practice Location Address
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Address Line | 1345 S PUEBLO BLVD
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City | PUEBLO
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State | CO
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Zip | 81005-1508
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Country | US
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Telephone | 623-910-5569
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Fax |
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Provider Business Mailing Address
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Address Line | 4542 VALLEYBROOK DR
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City | HIGHLANDS RANCH
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State | CO
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Zip | 80130-6965
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Country | US
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Telephone | 623-910-5569
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Fax |
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Authorized Official
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Title or Position | DENTIST/ OWNER
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Name | MICHAEL HALL
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Credential |
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Telephone | 801-602-0691
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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 | DEN 202339
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License Number State | CO
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