Provider Demographics
NPI:1699724831
Name:DEROSE CHILDREN'S DENTAL CLINIC, PC
Entity type:Organization
Organization Name:DEROSE CHILDREN'S DENTAL CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, LICENSING & CREDENTIALING
Authorized Official - Prefix:MS
Authorized Official - First Name:TRUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-750-0342
Mailing Address - Street 1:201 W 8TH ST
Mailing Address - Street 2:SUITE 810
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3038
Mailing Address - Country:US
Mailing Address - Phone:719-562-4447
Mailing Address - Fax:
Practice Address - Street 1:1022 LIBERTY LN
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-2039
Practice Address - Country:US
Practice Address - Phone:719-545-5775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-07
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO42852561Medicaid