MEDICARE: JADE DENTAL PROFESSIONALS

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	7157	CO

General Provider Information

NPI Number	:	1902213135
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JADE DENTAL PROFESSIONALS

Provider Business Mailing Address
First Line	:	703 N TEJON ST STE A
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-1050
Country	:	US
Telephone Number	:	719-313-8666
Fax Number	:

Provider Business Practice Location Address
First Line	:	703 N TEJON ST STE A
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-1050
Country	:	US
Telephone Number	:	719-313-8666
Fax Number	:

Authorized Official
Title or Position	:	ADMINSTRATOR
Name	:	MR. GREG L RODRIGUEZ
Credential	:
Telephone Number	:	719-633-0770

Provider Enumeration Date	:	07/21/2014
Last Update Date	:	07/21/2014

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