Provider Demographics
NPI:1104530542
Name:ELITE DENTAL GROUP CO SPRINGS INC
Entity type:Organization
Organization Name:ELITE DENTAL GROUP CO SPRINGS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KYU
Authorized Official - Middle Name:
Authorized Official - Last Name:JUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-471-1717
Mailing Address - Street 1:10700 E BETHANY DR STE 210
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-2680
Mailing Address - Country:US
Mailing Address - Phone:303-745-8828
Mailing Address - Fax:720-748-8867
Practice Address - Street 1:1855 S NEVADA AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905-2516
Practice Address - Country:US
Practice Address - Phone:719-471-1717
Practice Address - Fax:719-447-0605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-10
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1396261251Medicaid