Basic Information
Provider Information | |||||||||
NPI: | 1376676353 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GUAN | ||||||||
FirstName: | GLORIA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.D.S. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3205 N ACADEMY BLVD | ||||||||
Address2: | SUITE 130 | ||||||||
City: | COLORADO SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 809175147 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7196325700 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2828 INTERNATIONAL CIR | ||||||||
Address2: | SUITE 100 | ||||||||
City: | COLORADO SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 809103127 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7196325700 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/13/2007 | ||||||||
LastUpdateDate: | 04/04/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 54145 | CA | N |   | Dental Providers | Dentist |   | 122300000X | 9199 | NC | N |   | Dental Providers | Dentist |   | 1223P0221X | DR60353632 | WA | N |   | Dental Providers | Dentist | Pediatric Dentistry | 1223P0221X | DEN.00202661 | CO | Y |   | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
ID | Type | State | Issuer | Description | 11370866 | 05 | CO |   | MEDICAID |