Provider Demographics
NPI:1992063176
Name:MONUMENT CHILD DENTAL & ORTHODONTIC SPECIALISTS PC
Entity type:Organization
Organization Name:MONUMENT CHILD DENTAL & ORTHODONTIC SPECIALISTS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-282-6666
Mailing Address - Street 1:9334 GRAND CORDERA PKWY
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80924-7000
Mailing Address - Country:US
Mailing Address - Phone:719-282-6666
Mailing Address - Fax:719-203-5477
Practice Address - Street 1:850 SKY VISTA POINT
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80921-1400
Practice Address - Country:US
Practice Address - Phone:719-488-1101
Practice Address - Fax:719-488-1115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-25
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO96651223P0221X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO29102251Medicaid
CO86708350Medicaid