MEDICARE: MY LOCAL COLORADO DENTAL PRACTICE, LLC

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

General Provider Information

NPI Number	:	1891443073
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MY LOCAL COLORADO DENTAL PRACTICE, LLC

Provider Business Mailing Address
First Line	:	6110 BARNES RD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80922-2600
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2730 N GATE BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80921-3419
Country	:	US
Telephone Number	:	719-394-8048
Fax Number	:

Authorized Official
Title or Position	:	DATA ANALYST
Name	:	GREGORY KOSTELAC
Credential	:
Telephone Number	:	719-372-5605

Provider Enumeration Date	:	03/16/2022
Last Update Date	:	03/16/2022

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