MEDICARE: PIKES PEAK DENTAL X-RAY, INC

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	261QR0200X	Radiology Clinic/Center

General Provider Information

NPI Number	:	1619365020
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PIKES PEAK DENTAL X-RAY, INC

Provider Business Mailing Address
First Line	:	6010 ERIN PARK DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-3404
Country	:	US
Telephone Number	:	949-529-7227
Fax Number	:	888-870-2536

Provider Business Practice Location Address
First Line	:	6010 ERIN PARK DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-3404
Country	:	US
Telephone Number	:	949-529-7227
Fax Number	:	888-870-2536

Authorized Official
Title or Position	:	BILLING
Name	:	LIZ BASSIN
Credential	:
Telephone Number	:	949-529-7227

Provider Enumeration Date	:	01/07/2015
Last Update Date	:	01/07/2015

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