Basic Information
| Provider Information | |||||||||
| NPI: | 1174771802 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPROTT | ||||||||
| FirstName: | SIOBHIAN | ||||||||
| MiddleName: | MELINDA BACCHUS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS, MPA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BACCHUS | ||||||||
| OtherFirstName: | SIOBHIAN | ||||||||
| OtherMiddleName: | MELINDA | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DDS, MPA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2221 E BIJOU ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809098009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195761850 | ||||||||
| FaxNumber: | 7199553470 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401 GEORGIA AVE NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 20010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028295437 | ||||||||
| FaxNumber: | 2028299255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2008 | ||||||||
| LastUpdateDate: | 07/21/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | DN1857887 | MA | Y | Dental Providers | Dentist | Pediatric Dentistry | 1223P0221X | 0401412318 | VA | N | Dental Providers | Dentist | Pediatric Dentistry | 1223P0221X | DEN1000855 | DC | N | Dental Providers | Dentist | Pediatric Dentistry | 1223P0221X | 15112 | MD | N | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
| ID | Type | State | Issuer | Description | 037892500 | 05 | DC | MEDICAID |