Provider First Line Business Practice Location Address: 
110 W. ENT AVE
    Provider Second Line Business Practice Location Address: 
ATTN: 21 DS/SGGD- DENTAL SQUADRON
    Provider Business Practice Location Address City Name: 
PETERSON AFB
    Provider Business Practice Location Address State Name: 
CO
    Provider Business Practice Location Address Postal Code: 
80914-1540
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
719-556-1333
    Provider Business Practice Location Address Fax Number: 
719-556-1331
    Provider Enumeration Date: 
10/04/2005