Basic Information
| Provider Information | |||||||||
| NPI: | 1811417298 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PANDES | ||||||||
| FirstName: | BETHANY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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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 | ||||||||
| 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: | 06/26/2017 | ||||||||
| LastUpdateDate: | 06/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DEN00203279 | CO | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 1811417298 | 05 | CO | MEDICAID | 14037062 | 01 | CO | CAQH | OTHER |