Organization
MEDICAID DENTAL HOME
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MICHELLE VACHA RDH (EXECUTIVE DIRECTOR)
(719) 338-2195
Entity
Organization
Contact information
Practice address
2125 E LA SALLE ST, COLORADO SPRINGS, CO 80909-2274
(719) 310-3315
Mailing address
2604 FLINTRIDGE DR, COLORADO SPRINGS, CO 80918-4408
(719) 338-2195
Taxonomy
Speciality
Code
Description
License number
State
1223D0001X
Public Health Dentistry
Primary
8109
CO
124Q00000X
Dental Hygienist
903783
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
84887761
—
CO
Enumeration date
12/04/2013
Last updated
12/04/2013
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