1376989707 NPI number — MICHAEL KUNKEL DDS PROFESSIONAL LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376989707 NPI number — MICHAEL KUNKEL DDS PROFESSIONAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL KUNKEL DDS PROFESSIONAL LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376989707
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3475 BRIARGATE BLVD
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80920-4170
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-264-6070
Provider Business Mailing Address Fax Number:
719-264-6090

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3475 BRIARGATE BLVD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80920-4170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-264-6070
Provider Business Practice Location Address Fax Number:
719-264-6090
Provider Enumeration Date:
05/13/2013

Additional Information

Authorized Official

Authorized Official Last Name:
KUNKEL
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
719-264-6070

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  DEN.00201943 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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