# COUNTRY CLUB DENTAL PA

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Adventure Dental and Vision
- **Organization subpart:** No

## Provider details

- **NPI number:** 1699137109
- **Authorized official:** SHAUN URBANOZO (CREDENTIALING MANAGER)
- **Authorized official phone:** (719) 323-2362

## Contact information

- **Practice address:** 400 SW 29TH ST, SUITE M, TOPEKA, KS 66611-1164
- **Practice address phone:** (785) 783-5981
- **Practice address fax:** (785) 783-5982
- **Mailing address:** 2221 E BIJOU ST, STE 100, COLORADO SPRINGS, CO 80909-8009
- **Mailing address phone:** (719) 576-1850
- **Mailing address fax:** (719) 955-3470

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | — | KS | Yes |
| 1223G0001X | General Practice Dentistry | — | — | — |

## Other

- **Enumeration date:** 03/23/2016
- **Last updated:** 09/09/2025

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 201199030A | — | KS |