Provider Demographics
NPI:1811473861
Name:VSB COLORADO PROVIDERS PLLC
Entity type:Organization
Organization Name:VSB COLORADO PROVIDERS PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT AND OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DRIESSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-306-3215
Mailing Address - Street 1:1942 CAMINITO DE LA ESTRELLA
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-3000
Mailing Address - Country:US
Mailing Address - Phone:818-306-3215
Mailing Address - Fax:
Practice Address - Street 1:1750 TELSTAR DRIVE, SUITE 200
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920
Practice Address - Country:US
Practice Address - Phone:818-306-3215
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VSB COLORADO PROVIDERS PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty