1053690651 NPI number — WINDSOR PEDIATRIC DENTISTRY PLLC

Table of content: (NPI 1053690651)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053690651 NPI number — WINDSOR PEDIATRIC DENTISTRY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WINDSOR PEDIATRIC DENTISTRY 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:
1053690651
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1576 MAIN STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINDSOR
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-674-3247
Provider Business Mailing Address Fax Number:
970-460-0865

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1299 MAIN ST UNIT C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINDSOR
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80550-5918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-674-3247
Provider Business Practice Location Address Fax Number:
970-460-0865
Provider Enumeration Date:
08/12/2011

Additional Information

Authorized Official

Authorized Official Last Name:
SHONKA
Authorized Official First Name:
JILL
Authorized Official Middle Name:
MACKENZIE
Authorized Official Title or Position:
OWNER/DOCTOR
Authorized Official Telephone Number:
970-674-3247

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  10346 , 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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