Provider Demographics
NPI:1407926132
Name:MISNER PROFESSIONAL DENTAL CORP
Entity type:Organization
Organization Name:MISNER PROFESSIONAL DENTAL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:MISNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:719-323-2362
Mailing Address - Street 1:2221 E BIJOU ST STE 100
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-8009
Mailing Address - Country:US
Mailing Address - Phone:719-576-1850
Mailing Address - Fax:
Practice Address - Street 1:514 S ALVARADO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2904
Practice Address - Country:US
Practice Address - Phone:213-259-0606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51044122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty