MEDICARE: PAGOSA DENTAL CARE 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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	DEN00008224	CO

General Provider Information

NPI Number	:	1770018830
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAGOSA DENTAL CARE PC

Provider Business Mailing Address
First Line	:	189 TALISMAN DR
Second Line	:	STE E
City	:	PAGOSA SPGS
State	:	CO
Zip	:	81147-7916
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	189 TALISMAN DR
Second Line	:	STE E
City	:	PAGOSA SPGS
State	:	CO
Zip	:	81147-7916
Country	:	US
Telephone Number	:	970-731-6600
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	WILLIAM THORNELL
Credential	:
Telephone Number	:	970-731-6600

Provider Enumeration Date	:	04/26/2017
Last Update Date	:	04/26/2017

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