Active NPI
Eagleridge Dental
- Dentist
- Walsenburg, CO
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- Legal business name
- EAGLERIDGE DENTAL
- Practice address
- 104 E 6TH St
Walsenburg, CO 81089-2020 - Phone
- (719) 738-2544
- Fax
- (719) 738-3747
- NPI assigned
- Mar 3, 2020
- Last updated
- Mar 3, 2020
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Dr. Charles Wohlwend, DDS
- Title
- Dentist
- Phone
- (719) 542-1212
Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | NU | Primary |
Addresses
Primary practice location
104 E 6TH St
Walsenburg, CO 81089-2020
Mailing address
1044 Eagleridge Blvd
Pueblo, CO 81008-2130
Phone (719) 542-1212
Other practice location 1
1044 Eagleridge Blvd
Pueblo, CO 81008-2130
Phone (719) 542-1212
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 10 | Medicaid | CO |
National Provider Directory
National Provider Directory- Tax ID family
- Charles Wohlwend Ddspc
Other organizations with this tax ID 1
Organizations that report the same tax identification number in the National Provider Directory.
Practitioners & affiliated clinicians
Practitioners 1
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.
-
- General Practice Dentistry
- Pueblo, CO
- NPI 1366423279
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1583193600000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1583193600000",
"number": "1487288106",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1044 EAGLERIDGE BLVD",
"city": "PUEBLO",
"state": "CO",
"postal_code": "810082130",
"telephone_number": "719-542-1212",
"fax_number": "719-544-3854"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "104 E 6TH ST",
"city": "WALSENBURG",
"state": "CO",
"postal_code": "810892020",
"telephone_number": "719-738-2544",
"fax_number": "719-738-3747"
}
],
"practiceLocations": [
{
"address_1": "1044 Eagleridge Blvd",
"address_purpose": "LOCATION",
"city": "Pueblo",
"state": "CO",
"postal_code": "810082130",
"country_code": "US",
"telephone_number": "719-542-1212",
"fax_number": "719-544-3854",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"organization_name": "EAGLERIDGE DENTAL",
"organizational_subpart": "NO",
"enumeration_date": "2020-03-03",
"last_updated": "2020-03-03",
"certification_date": "2020-03-03",
"status": "A",
"authorized_official_last_name": "WOHLWEND",
"authorized_official_first_name": "CHARLES",
"authorized_official_title_or_position": "DENTIST",
"authorized_official_telephone_number": "719-542-1212",
"authorized_official_name_prefix": "Dr.",
"authorized_official_credential": "DDS"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "NU",
"license": null,
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "10",
"state": "CO"
}
],
"endpoints": [],
"other_names": []
}Other providers in Walsenburg, CO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 3, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.