MEDICARE: CROSSROADS FAMILY 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	1223G0001X	General Practice Dentistry	10399	CO

General Provider Information

NPI Number	:	1396137907
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROSSROADS FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	1079 SPACE CENTER DR
Second Line	:	SUITE 100
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80915-3612
Country	:	US
Telephone Number	:	719-596-3481
Fax Number	:	719-596-9114

Provider Business Practice Location Address
First Line	:	1079 SPACE CENTER DR
Second Line	:	SUITE 100
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80915-3612
Country	:	US
Telephone Number	:	719-596-3481
Fax Number	:	719-596-9114

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. RYAN TYNG
Credential	:	D.M.D
Telephone Number	:	719-596-3481

Provider Enumeration Date	:	02/19/2015
Last Update Date	:	02/19/2015

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