MEDICARE: BROADMOOR LAKE DENTAL

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	104909	CO

General Provider Information

NPI Number	:	1801286919
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROADMOOR LAKE DENTAL

Provider Business Mailing Address
First Line	:	155 LAKE AVE STE 201
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-3717
Country	:	US
Telephone Number	:	719-375-5201
Fax Number	:	844-656-9696

Provider Business Practice Location Address
First Line	:	155 LAKE AVE STE 201
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-3717
Country	:	US
Telephone Number	:	719-375-5201
Fax Number	:	844-656-9696

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MARC VAN NESS
Credential	:	D.M.D.
Telephone Number	:	719-375-5201

Provider Enumeration Date	:	01/27/2015
Last Update Date	:	07/21/2021

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Directions to “BROADMOOR LAKE DENTAL ” Practice Location

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