Provider Demographics
NPI:1467627281
Name:PAWEL R BIELECKI, DDS, PC
Entity type:Organization
Organization Name:PAWEL R BIELECKI, DDS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:HERRERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-696-9009
Mailing Address - Street 1:2603 VINEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-3370
Mailing Address - Country:US
Mailing Address - Phone:719-564-6464
Mailing Address - Fax:719-564-1888
Practice Address - Street 1:2603 VINEWOOD LN
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-3370
Practice Address - Country:US
Practice Address - Phone:719-564-6464
Practice Address - Fax:719-564-1888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO94921223G0001X
CO88091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO83505318Medicaid