=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902447378
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUDITH GILL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2019
-----------------------------------------------------
Last Update Date | 10/07/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5426 N ACADEMY BLVD STE 105
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80918-3686
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-249-4760
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7225 DANDELION CT
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80922-3620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-903-2339
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------