Provider Demographics
NPI:1699100982
Name:PUEBLO DENTAL CENTER OF PUEBLO
Entity type:Organization
Organization Name:PUEBLO DENTAL CENTER OF PUEBLO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:COMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-582-4222
Mailing Address - Street 1:3208 N ACADEMY BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5161
Mailing Address - Country:US
Mailing Address - Phone:719-597-3700
Mailing Address - Fax:719-597-7507
Practice Address - Street 1:1700 N SALEM AVE
Practice Address - Street 2:SUITE B
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-2846
Practice Address - Country:US
Practice Address - Phone:719-582-4222
Practice Address - Fax:719-597-7507
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRESTIGE DENTAL CENTERS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO79891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPENDINGMedicaid