MEDICARE: DR. ARLENE CANCHOLA DMD

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	107623	CA
2	122300000X	Dentist	00205147	CO

General Provider Information

NPI Number	:	1881328979
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ARLENE CANCHOLA DMD

Provider Business Mailing Address
First Line	:	3655 MESA TOP DR
Second Line	:
City	:	MONUMENT
State	:	CO
Zip	:	80132-7968
Country	:	US
Telephone Number	:	562-501-8791
Fax Number	:

Provider Business Practice Location Address
First Line	:	3655 MESA TOP DR
Second Line	:
City	:	MONUMENT
State	:	CO
Zip	:	80132-7968
Country	:	US
Telephone Number	:	562-501-8791
Fax Number	:

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

Provider Enumeration Date	:	07/13/2022
Last Update Date	:	07/29/2022

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