MEDICARE: MISNER DENTAL CORP

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	51044	CA

General Provider Information

NPI Number	:	1811275670
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISNER DENTAL CORP

Provider Business Mailing Address
First Line	:	2221 E BIJOU ST STE 100
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-8009
Country	:	US
Telephone Number	:	818-335-2100
Fax Number	:

Provider Business Practice Location Address
First Line	:	2621 ZOE AVE
Second Line	:	SUITE A
City	:	HUNTINGTON PARK
State	:	CA
Zip	:	90255-4131
Country	:	US
Telephone Number	:	818-335-2100
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	SHAUN URBANOZO
Credential	:
Telephone Number	:	719-323-2362

Provider Enumeration Date	:	07/28/2011
Last Update Date	:	07/03/2023

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