Provider Demographics
NPI:1194942573
Name:ORCHARD SPRINGS DENTAL
Entity type:Organization
Organization Name:ORCHARD SPRINGS DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:RIEG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-276-0117
Mailing Address - Street 1:410 MACON ST
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212
Mailing Address - Country:US
Mailing Address - Phone:719-276-0117
Mailing Address - Fax:719-276-0653
Practice Address - Street 1:410 MACON AVE
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-3225
Practice Address - Country:US
Practice Address - Phone:719-276-0117
Practice Address - Fax:719-276-0653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8336122300000X
CO106275122300000X
CO105973122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO88834042Medicaid
CO17258871Medicaid