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NPI Code Detail

MEDICARE: PEDIATRIC DENTAL GROUP II, LLC

MEDICARE: PEDIATRIC DENTAL GROUP II, 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
1261QD0000XDental Clinic/Center

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
13942OTHEROKOK STATE DENTAL LICENSE

General Provider Information

NPI Number : 1912553215
Entity Type Code : Organization
Provider Name (Legal Business Name) : PEDIATRIC DENTAL GROUP II, LLC
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 : 719-576-1850
Fax Number : 719-955-3470
Provider Business Practice Location Address
First Line : 1200 S AIR DEPOT BLVD
Second Line :
City : MIDWEST CITY
State : OK
Zip : 73110-4866
Country : US
Telephone Number : 918-872-7009
Fax Number :
Authorized Official
Title or Position : CREDENTIALING MANAGER
Name : SHAUN URBANOZO
Credential :
Telephone Number : 719-323-2362
Provider Enumeration Date : 08/13/2019
Last Update Date : 03/30/2020

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