Medicaid Dental Home

Primary specialty

Public Health DentistryTaxonomy code 1223D0001X

License

8109 Issued in CO

Legal business name

MEDICAID DENTAL HOME

Practice address

2125 E la Salle St
Colorado Springs, CO 80909-2274

Phone

(719) 310-3315

NPI assigned

Dec 4, 2013

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Michelle Vacha, RDH

Title

Executive Director

Phone

(719) 338-2195

Specialties & licenses 2

Addresses

Other identifiers 1

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Pam Bradow, RDH

  • Dental Hygienist
  • Colorado Springs, CO
  • NPI 1790103570
  NPD (past)
• Patricia Michelle Vacha, RDH

  • Dental Hygienist
  • Colorado Springs, CO
  • NPI 1376865642
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1386115200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1386115200000",
    "number": "1336570167",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2604 FLINTRIDGE DR",
            "city": "COLORADO SPRINGS",
            "state": "CO",
            "postal_code": "809184408",
            "telephone_number": "719-338-2195"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2125 E LA SALLE ST",
            "city": "COLORADO SPRINGS",
            "state": "CO",
            "postal_code": "809092274",
            "telephone_number": "719-310-3315"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MEDICAID DENTAL HOME",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-12-04",
        "last_updated": "2013-12-04",
        "status": "A",
        "authorized_official_last_name": "VACHA",
        "authorized_official_first_name": "MICHELLE",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "719-338-2195",
        "authorized_official_credential": "RDH"
    },
    "taxonomies": [
        {
            "code": "1223D0001X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dentist, Dental Public Health",
            "state": "CO",
            "license": "8109",
            "primary": true
        },
        {
            "code": "124Q00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dental Hygienist",
            "state": "CO",
            "license": "903783",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "84887761",
            "state": "CO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Ricky Medel, M.D.
• Kaylin Medellin
• Medevals of Colorado, Inc.
• Eric Philip Mediavilla, DDS
• Laurie Marguerite Mediavilla, P.A.-C
• Medicaid Management Inc
• Medical Recording Industry
• Medical Restoration Centers, LLC
• Medical Ride LLC
• Medicarriage LLC

• Public Health Dentistry in Colorado Springs, CO
• Providers in Colorado Springs, CO by specialty
• Public Health Dentistry in Colorado

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 4, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.