Provider Demographics
NPI:1386750081
Name:SLACK, NEILL CURTIS (DDS)
Entity type:Individual
Prefix:DR
First Name:NEILL
Middle Name:CURTIS
Last Name:SLACK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5925 LEHMAN DR. #2
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918
Mailing Address - Country:US
Mailing Address - Phone:719-698-6966
Mailing Address - Fax:844-335-8493
Practice Address - Street 1:5925 LEHMAN DR. #2
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918
Practice Address - Country:US
Practice Address - Phone:719-698-6966
Practice Address - Fax:844-335-8493
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO55211223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO2006267211OtherTAX ID NUMBER