Basic Information
| Provider Information | |||||||||
| NPI: | 1598934853 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HERO DENTAL OF SPOKANE PC | ||||||||
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| OtherOrganizationName: | ADVENTURE DENTAL AND ORTHODONTICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2221 E BIJOU ST | ||||||||
| Address2: | STE 100 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809098009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7199558896 | ||||||||
| FaxNumber: | 7199553470 | ||||||||
| Practice Location | |||||||||
| Address1: | 82 E FRANCIS AVE | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992081070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094844746 | ||||||||
| FaxNumber: | 5094848281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2008 | ||||||||
| LastUpdateDate: | 03/29/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SOUDER | ||||||||
| AuthorizedOfficialFirstName: | CHARLOTTE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7193232362 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 1223G0001X | WA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.