MEDICARE: NORTH ACADEMY DENTAL PARTNERS PROF LLP

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1992032874
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH ACADEMY DENTAL PARTNERS PROF LLP

Provider Business Mailing Address
First Line	:	1634 YORK RD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-1033
Country	:	US
Telephone Number	:	719-522-0800
Fax Number	:	719-522-0810

Provider Business Practice Location Address
First Line	:	1634 YORK RD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-1033
Country	:	US
Telephone Number	:	719-522-0800
Fax Number	:	719-522-0810

Authorized Official
Title or Position	:	PARTNER
Name	:	ROBERT BRYAN WYETH
Credential	:	DMD
Telephone Number	:	719-522-0800

Provider Enumeration Date	:	11/12/2009
Last Update Date	:	07/21/2015

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