Provider Demographics
NPI:1174700629
Name:MICHAEL J. PURCELL, DDS
Entity type:Organization
Organization Name:MICHAEL J. PURCELL, DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:PURCELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-369-8484
Mailing Address - Street 1:1640 FORTINO BLVD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1856
Mailing Address - Country:US
Mailing Address - Phone:719-543-7123
Mailing Address - Fax:719-253-7761
Practice Address - Street 1:1640 FORTINO BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1856
Practice Address - Country:US
Practice Address - Phone:719-543-7123
Practice Address - Fax:719-253-7761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COC07055261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02070555Medicaid
CO789815OtherUNITED CONCORDIA