Provider Demographics
NPI:1841342300
Name:BLUE MESA DENTAL ASSOC PC
Entity type:Organization
Organization Name:BLUE MESA DENTAL ASSOC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:NORMA
Authorized Official - Middle Name:BERENICE
Authorized Official - Last Name:GRIJALUA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-337-0789
Mailing Address - Street 1:1700 S CHAMBERS RD
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80017-5023
Mailing Address - Country:US
Mailing Address - Phone:303-337-0789
Mailing Address - Fax:303-671-2601
Practice Address - Street 1:1700 S CHAMBERS RD
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80017-5023
Practice Address - Country:US
Practice Address - Phone:303-337-0789
Practice Address - Fax:303-671-2601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8934122300000X
CO6619122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty