MEDICARE: IMAGINE KIDS DENTISTRY 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	261QD0000X	Dental Clinic/Center
2	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1336786250
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMAGINE KIDS DENTISTRY PLLC

Provider Business Mailing Address
First Line	:	5467 PADDINGTON CREEK PL
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80924-2083
Country	:	US
Telephone Number	:	719-722-4999
Fax Number	:

Provider Business Practice Location Address
First Line	:	6620 CAMDEN BLVD
Second Line	:
City	:	FOUNTAIN
State	:	CO
Zip	:	80817-2505
Country	:	US
Telephone Number	:	719-722-4999
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PEDIATRIC DENTIST
Name	:	CHRISTOPHER JOHNSON
Credential	:	DDS
Telephone Number	:	719-722-4999

Provider Enumeration Date	:	12/10/2019
Last Update Date	:	02/12/2020

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