MEDICARE: BLUE MESA DENTAL ASSOC 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	122300000X	Dentist	8934	CO
2	122300000X	Dentist	6619	CO

General Provider Information

NPI Number	:	1841342300
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE MESA DENTAL ASSOC PC

Provider Business Mailing Address
First Line	:	1700 S CHAMBERS RD
Second Line	:
City	:	AURORA
State	:	CO
Zip	:	80017-5023
Country	:	US
Telephone Number	:	303-337-0789
Fax Number	:	303-671-2601

Provider Business Practice Location Address
First Line	:	1700 S CHAMBERS RD
Second Line	:
City	:	AURORA
State	:	CO
Zip	:	80017-5023
Country	:	US
Telephone Number	:	303-337-0789
Fax Number	:	303-671-2601

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MS. NORMA BERENICE GRIJALUA
Credential	:
Telephone Number	:	303-337-0789

Provider Enumeration Date	:	01/17/2007
Last Update Date	:	08/22/2020

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