MEDICARE: LIFE PEDIATRIC DENTISTRY

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	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1326864778
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE PEDIATRIC DENTISTRY

Provider Business Mailing Address
First Line	:	505 N BEAR PAW LN
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-3279
Country	:	US
Telephone Number	:	415-990-6229
Fax Number	:

Provider Business Practice Location Address
First Line	:	4262 ROYAL PINE DR STE 100
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-2824
Country	:	US
Telephone Number	:	719-413-8446
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ELIZABETH PAULSEN
Credential	:	DDS
Telephone Number	:	415-990-6229

Provider Enumeration Date	:	12/02/2024
Last Update Date	:	12/02/2024

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