Basic Information
Provider Information | |||||||||
NPI: | 1720720196 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CO SPECIALTY DENTAL SERVICES PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1610 54TH AVE N STE 205 | ||||||||
Address2: |   | ||||||||
City: | NASHVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 372091442 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 6665 DELMONICO DR STE A | ||||||||
Address2: |   | ||||||||
City: | COLORADO SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 809191895 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195963113 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/07/2022 | ||||||||
LastUpdateDate: | 04/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DASCH | ||||||||
AuthorizedOfficialFirstName: | CHARLOTTE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF PROVIDER RELATIONS | ||||||||
AuthorizedOfficialTelephone: | 5046380303 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CO SPECIALTY DENTAL SERVICES PLLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
No ID Information.