MEDICARE: PAGOSA SPRINGS FAMILY DENTAL 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	122300000X	Dentist

General Provider Information

NPI Number	:	1528855830
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAGOSA SPRINGS FAMILY DENTAL LLC

Provider Business Mailing Address
First Line	:	245 PINES CLUB PL
Second Line	:
City	:	PAGOSA SPRINGS
State	:	CO
Zip	:	81147-9304
Country	:	US
Telephone Number	:	970-528-3384
Fax Number	:	970-507-9898

Provider Business Practice Location Address
First Line	:	2363 EAGLE DR UNIT A
Second Line	:
City	:	PAGOSA SPRINGS
State	:	CO
Zip	:	81147-9058
Country	:	US
Telephone Number	:	970-528-3384
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JUSTIN J NYLUND
Credential	:	DDS
Telephone Number	:	970-528-3384

Provider Enumeration Date	:	04/21/2025
Last Update Date	:	12/30/2025

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