MEDICARE: MONUMENT DENTAL PROFESSIONALS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	9788	CO

General Provider Information

NPI Number	:	1063647584
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MONUMENT DENTAL PROFESSIONALS LLC

Provider Business Mailing Address
First Line	:	1258 INTERQUEST PKWY
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80921-4183
Country	:	US
Telephone Number	:	719-484-0043
Fax Number	:	719-487-3153

Provider Business Practice Location Address
First Line	:	1258 INTERQUEST PKWY
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80921-4183
Country	:	US
Telephone Number	:	719-484-0043
Fax Number	:	719-487-3153

Authorized Official
Title or Position	:	RECEPTIONIST
Name	:	MS. CINDY BOSCH
Credential	:
Telephone Number	:	719-484-0043

Provider Enumeration Date	:	05/28/2009
Last Update Date	:	09/13/2019

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