Basic Information
| Provider Information | |||||||||
| NPI: | 1659880169 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DDS CATALYST PAGOSA, LLC | ||||||||
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| OtherOrganizationName: | DDS CATALYST PAGOSA, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3501 N BUTLER AVE STE 104 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874016430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055644470 | ||||||||
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| Practice Location | |||||||||
| Address1: | 308 N. PAGOSA STREET | ||||||||
| Address2: | |||||||||
| City: | PAGOSA SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705071300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2017 | ||||||||
| LastUpdateDate: | 09/27/2017 | ||||||||
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| AuthorizedOfficialLastName: | ASHBY | ||||||||
| AuthorizedOfficialFirstName: | ANDREW | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3038102890 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DMD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | DEN.00009933 | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.