Organization
COUNTRY CLUB DENTAL PA
Active
Other names
Adventure Dental and Vision
Organization subpart
No
Provider details
NPI number
Authorized official
SHAUN URBANOZO (CREDENTIALING MANAGER)
(719) 323-2362
Entity
Organization
Contact information
Practice address
400 SW 29TH ST, SUITE M, TOPEKA, KS 66611-1164
(785) 783-5981
(785) 783-5982
Mailing address
2221 E BIJOU ST, STE 100, COLORADO SPRINGS, CO 80909-8009
(719) 576-1850
(719) 955-3470
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
—
KS
1223G0001X
General Practice Dentistry
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
201199030A
—
KS
Enumeration date
03/23/2016
Last updated
09/09/2025
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