Provider Demographics
NPI:1528855830
Name:PAGOSA SPRINGS FAMILY DENTAL LLC
Entity type:Organization
Organization Name:PAGOSA SPRINGS FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:NYLUND
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-565-0609
Mailing Address - Street 1:245 PINES CLUB PL
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-9304
Mailing Address - Country:US
Mailing Address - Phone:505-565-0609
Mailing Address - Fax:
Practice Address - Street 1:2363 EAGLE DR UNIT A
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147-9058
Practice Address - Country:US
Practice Address - Phone:505-565-0609
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-21
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty