Provider Demographics
NPI:1386196665
Name:COLORADO DEPARTMENT OF CORRECTIONS
Entity type:Organization
Organization Name:COLORADO DEPARTMENT OF CORRECTIONS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:OTTEM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-775-7666
Mailing Address - Street 1:49030 STATE HWY 71
Mailing Address - Street 2:
Mailing Address - City:LIMON
Mailing Address - State:CO
Mailing Address - Zip Code:80826-0001
Mailing Address - Country:US
Mailing Address - Phone:719-775-9221
Mailing Address - Fax:
Practice Address - Street 1:49030 STATE HWY 71
Practice Address - Street 2:
Practice Address - City:LIMON
Practice Address - State:CO
Practice Address - Zip Code:80826-0001
Practice Address - Country:US
Practice Address - Phone:719-775-9221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00104436305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service