Provider Demographics
NPI:1154970366
Name:EDEN DENTAL PUEBLO PC
Entity type:Organization
Organization Name:EDEN DENTAL PUEBLO PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:HERRERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-978-8527
Mailing Address - Street 1:2041 PEPPER LN
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-3276
Mailing Address - Country:US
Mailing Address - Phone:719-696-9009
Mailing Address - Fax:
Practice Address - Street 1:2041 PEPPER LN
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-3276
Practice Address - Country:US
Practice Address - Phone:719-696-9009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-10
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty