Basic Information
| Provider Information | |||||||||
| NPI: | 1275873549 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HERO DENTAL OF AURORA PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ADVENTURE DENTAL, VISION AND ORTHODONTICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2221 E BIJOU ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809098009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7199558896 | ||||||||
| FaxNumber: | 7199553470 | ||||||||
| Practice Location | |||||||||
| Address1: | 15121 E MISSISSIPPI AVE | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800123746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038021022 | ||||||||
| FaxNumber: | 3038021023 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2013 | ||||||||
| LastUpdateDate: | 11/19/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | URBANOZO | ||||||||
| AuthorizedOfficialFirstName: | SHAUN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7193232362 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | 122300000X | CO | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 32373074 | 05 | CO | MEDICAID |