MEDICARE: ERINDALE DENTAL CENTER

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

General Provider Information

NPI Number	:	1285151258
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ERINDALE DENTAL CENTER

Provider Business Mailing Address
First Line	:	6020 ERIN PARK DR STE B
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-3429
Country	:	US
Telephone Number	:	719-266-9393
Fax Number	:	719-266-9494

Provider Business Practice Location Address
First Line	:	6020 ERIN PARK DR STE B
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-3429
Country	:	US
Telephone Number	:	719-266-9393
Fax Number	:	719-266-9494

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. GREG RODRIGUEZ
Credential	:
Telephone Number	:	719-266-9393

Provider Enumeration Date	:	08/29/2017
Last Update Date	:	08/29/2017

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