Basic Information
| Provider Information | |||||||||
| NPI: | 1700489903 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ACADEMY KIDS DENTAL CENTER PC | ||||||||
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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 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2436 S ACADEMY BLVD | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809162408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193912336 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2020 | ||||||||
| LastUpdateDate: | 11/19/2020 | ||||||||
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| AuthorizedOfficialLastName: | URBANOZO | ||||||||
| AuthorizedOfficialFirstName: | SHAUN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7193232362 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ACADEMY KIDS DENTAL CENTER PC | ||||||||
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| NPICertificationDate: | 11/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 66286026 | 05 | CO | MEDICAID |