Provider Demographics
NPI:1396137907
Name:CROSSROADS FAMILY DENTISTRY
Entity type:Organization
Organization Name:CROSSROADS FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TYNG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:719-596-3481
Mailing Address - Street 1:1079 SPACE CENTER DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80915-3612
Mailing Address - Country:US
Mailing Address - Phone:719-596-3481
Mailing Address - Fax:719-596-9114
Practice Address - Street 1:1079 SPACE CENTER DR
Practice Address - Street 2:SUITE 100
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80915-3612
Practice Address - Country:US
Practice Address - Phone:719-596-3481
Practice Address - Fax:719-596-9114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-19
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO103991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty