Provider Demographics
NPI:1124493291
Name:HERO DENTAL OF NE DENVER PC
Entity type:Organization
Organization Name:HERO DENTAL OF NE DENVER PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:
Authorized Official - Last Name:URBANOZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-323-2362
Mailing Address - Street 1:2221 E BIJOU ST STE 100
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-8009
Mailing Address - Country:US
Mailing Address - Phone:719-955-8896
Mailing Address - Fax:719-955-3470
Practice Address - Street 1:9333 E COLFAX AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80010-1919
Practice Address - Country:US
Practice Address - Phone:720-697-5332
Practice Address - Fax:720-257-5337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-01
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO122300000X
CODEN00007992122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO57720096Medicaid