Basic Information
| Provider Information | |||||||||
| NPI: | 1164182242 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DENTISTS OF BROADMOOR, LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 920050 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753920050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148458890 | ||||||||
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| Practice Location | |||||||||
| Address1: | 160 EAST CHEYENNE ROAD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192498775 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2021 | ||||||||
| LastUpdateDate: | 12/30/2021 | ||||||||
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| AuthorizedOfficialLastName: | GILLETTE-BACKSTROM | ||||||||
| AuthorizedOfficialFirstName: | JANICA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7192498775 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | 12/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.