Organization
BROADMOOR DENTAL, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. NICOLAS ROGER PRUETT D.D.S. (OWNER/DENTIST)
(719) 576-5566
Entity
Organization
Contact information
Practice address
1930 S NEVADA AVE, COLORADO SPRINGS, CO 80905-3407
(719) 576-5566
(719) 576-1100
Mailing address
1930 S NEVADA AVE, COLORADO SPRINGS, CO 80905-3407
(719) 576-5566
(719) 576-1100
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
8913
CO
1223G0001X
General Practice Dentistry
9952
CO
1223G0001X
General Practice Dentistry
9966
CO
124Q00000X
Dental Hygienist
905802
CO
124Q00000X
Dental Hygienist
905995
CO
124Q00000X
Dental Hygienist
906138
CO
Other
Enumeration date
11/17/2010
Last updated
11/17/2010
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