MEDICARE: SOUTH SPRINGS DENTAL PROFESSIONAL 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	1223E0200X	Endodontics	10397	CO
2	1223P0300X	Periodontics	10397	CO
3	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	10397	CO
4	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	10397	CO
5	1223G0001X	General Practice Dentistry	10397	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10397	OTHER	CO	DENTAL

General Provider Information

NPI Number	:	1659702769
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH SPRINGS DENTAL PROFESSIONAL LLC

Provider Business Mailing Address
First Line	:	6514 S ACADEMY BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-8614
Country	:	US
Telephone Number	:	719-494-0718
Fax Number	:

Provider Business Practice Location Address
First Line	:	6514 S ACADEMY BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-8614
Country	:	US
Telephone Number	:	719-494-0718
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. DOUGLAS PEAK
Credential	:
Telephone Number	:	719-494-0718

Provider Enumeration Date	:	11/29/2013
Last Update Date	:	11/29/2013

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