MEDICARE: UNION BLVD DENTAL PLLC

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	:	1295342640
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNION BLVD DENTAL PLLC

Provider Business Mailing Address
First Line	:	3920 N UNION BLVD STE 380
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80907-4922
Country	:	US
Telephone Number	:	719-591-0091
Fax Number	:

Provider Business Practice Location Address
First Line	:	3920 N UNION BLVD STE 380
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80907-4922
Country	:	US
Telephone Number	:	719-591-0091
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF CREDENTIALING
Name	:	FAITH GASKINS
Credential	:
Telephone Number	:	972-869-3789

Provider Enumeration Date	:	09/29/2020
Last Update Date	:	09/29/2020

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