Basic Information
| Provider Information | |||||||||
| NPI: | 1851476089 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MISNER | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | SUZANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| 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: | 10/26/2006 | ||||||||
| LastUpdateDate: | 02/20/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 61146 | KS | N | Dental Providers | Dentist | 122300000X | DE60310664 | WA | N | Dental Providers | Dentist | 122400000X | DD3822 | NM | N | Dental Providers | Denturist | 122300000X | DEN00009208 | CO | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 185147089 | 05 | WA | MEDICAID | 1851476089 | 05 | CO | MEDICAID | 85752011 | 05 | NM | MEDICAID | 20113080A | 05 | KS | MEDICAID |