1730545757 NPI number — EXCELLENCE IN DENTISTRY OF PUEBLO ONE PLLC

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 1730545757 NPI number — EXCELLENCE IN DENTISTRY OF PUEBLO ONE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXCELLENCE IN DENTISTRY OF PUEBLO ONE PLLC
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:
1730545757
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9920 WADSWORTH PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOMFIELD
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80021-6847
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-425-1000
Provider Business Mailing Address Fax Number:
303-425-1026

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1800 FORTINO BLVD
Provider Second Line Business Practice Location Address:
SUITE #1
Provider Business Practice Location Address City Name:
PUEBLO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81008-1890
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-545-1400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/06/2016

Additional Information

Authorized Official

Authorized Official Last Name:
SKINNER
Authorized Official First Name:
KENDALL
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
303-425-1000

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  10691 , 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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