Basic Information
| Provider Information | |||||||||
| NPI: | 1225478183 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUNIVEN | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | DDS | ||||||||
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| 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: | 2027 CERRILLOS RD | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875053269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855397401 | ||||||||
| FaxNumber: | 7857768415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2013 | ||||||||
| LastUpdateDate: | 06/13/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 61016 | KS | N | Dental Providers | Dentist | 122300000X | DD4394 | NM | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 29658551 | 05 | NM | MEDICAID |