1578721106 NPI number — SMILES FOR COLORADO ORTHODONTICS, PC

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 1578721106 NPI number — SMILES FOR COLORADO ORTHODONTICS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SMILES FOR COLORADO ORTHODONTICS, PC
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:
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:
1578721106
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8115 NIGHT BLUFF DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78255-3300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-264-3102
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1539 S 8TH ST STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80906-1977
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-227-7645
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
TERRY
Authorized Official First Name:
BANGORN
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
719-227-7645

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 99488361 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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