MEDICARE: DR. NEILL CURTIS SLACK D.D.S.

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	5521	CO
2	122300000X	Dentist	5521	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2006267211	OTHER	CO	TAX ID NUMBER

General Provider Information

NPI Number	:	1386750081
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NEILL CURTIS SLACK D.D.S.

Provider Business Mailing Address
First Line	:	5925 LEHMAN DR. #2
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918
Country	:	US
Telephone Number	:	719-698-6966
Fax Number	:	844-335-8493

Provider Business Practice Location Address
First Line	:	5925 LEHMAN DR. #2
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918
Country	:	US
Telephone Number	:	719-698-6966
Fax Number	:	844-335-8493

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2006
Last Update Date	:	06/07/2021

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