MEDICARE: DR. SHAUN SOUCIE D.D.S.

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	019.027172	IL
2	1223E0200X	Endodontics	10040	CO

General Provider Information

NPI Number	:	1780890608
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHAUN SOUCIE D.D.S.

Provider Business Mailing Address
First Line	:	753 MALETA LN
Second Line	:	201
City	:	CASTLE ROCK
State	:	CO
Zip	:	80108-7605
Country	:	US
Telephone Number	:	720-221-7774
Fax Number	:

Provider Business Practice Location Address
First Line	:	753 MALETA LN
Second Line	:	201
City	:	CASTLE ROCK
State	:	CO
Zip	:	80108-7605
Country	:	US
Telephone Number	:	720-221-7774
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2007
Last Update Date	:	12/22/2010

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