MEDICARE: COLORADO SPRINGS PEDIATRIC DENTISTRY, PC

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	:	1396348884
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLORADO SPRINGS PEDIATRIC DENTISTRY, PC

Provider Business Mailing Address
First Line	:	9480 BRIAR VILLAGE PT STE 301
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-7923
Country	:	US
Telephone Number	:	719-522-0123
Fax Number	:	719-266-6614

Provider Business Practice Location Address
First Line	:	660 SOUTHPOINTE CT STE 100
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-3806
Country	:	US
Telephone Number	:	719-522-0123
Fax Number	:	719-375-8556

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	CASSIE MICHELLE SEARS
Credential	:
Telephone Number	:	719-522-0123

Provider Enumeration Date	:	11/18/2020
Last Update Date	:	11/18/2020

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