Provider Demographics
NPI:1992577860
Name:PUEBLO DENTAL SERVICES LLC
Entity type:Organization
Organization Name:PUEBLO DENTAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MEHRON
Authorized Official - Middle Name:
Authorized Official - Last Name:KAZEMI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-669-8908
Mailing Address - Street 1:1831 BOGUS PL
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80921-3872
Mailing Address - Country:US
Mailing Address - Phone:303-669-8908
Mailing Address - Fax:
Practice Address - Street 1:200 W 29TH ST # B
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1004
Practice Address - Country:US
Practice Address - Phone:719-542-9374
Practice Address - Fax:719-542-9433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-24
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty