MEDICARE: AUSTINBLUFFS DENTAL PROF. LLC

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	9850	CO

General Provider Information

NPI Number	:	1427360254
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUSTINBLUFFS DENTAL PROF. LLC

Provider Business Mailing Address
First Line	:	3952 N ACADEMY BLVD STE A
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80917-5910
Country	:	US
Telephone Number	:	719-591-1811
Fax Number	:	719-591-2032

Provider Business Practice Location Address
First Line	:	3952 NORTH ACADEMY
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80917
Country	:	US
Telephone Number	:	719-591-1811
Fax Number	:	719-591-2032

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. JENNIFFER RENEE MARTINEZ
Credential	:	DDS
Telephone Number	:	719-591-1811

Provider Enumeration Date	:	07/09/2010
Last Update Date	:	07/09/2010

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