Provider Demographics
NPI:1427483486
Name:MILES C. HUMBLE, LLC
Entity type:Organization
Organization Name:MILES C. HUMBLE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:MINNICH
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:719-576-6551
Mailing Address - Street 1:202 E CHEYENNE MOUNTAIN BLVD
Mailing Address - Street 2:STE. E
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-3769
Mailing Address - Country:US
Mailing Address - Phone:719-576-6551
Mailing Address - Fax:719-576-8722
Practice Address - Street 1:202 E CHEYENNE MOUNTAIN BLVD
Practice Address - Street 2:STE. E
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3769
Practice Address - Country:US
Practice Address - Phone:719-576-6551
Practice Address - Fax:719-576-8722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO98771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty