Provider Demographics
NPI:1356759054
Name:SOUTHERN COLORADO ORTHODONTICS, PLLC
Entity type:Organization
Organization Name:SOUTHERN COLORADO ORTHODONTICS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIMHALL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:435-881-7110
Mailing Address - Street 1:5200 LA RANDA DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-3532
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3955 SANDALWOOD LN
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-2586
Practice Address - Country:US
Practice Address - Phone:719-564-3333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-25
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002021771223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty