Basic Information
| Provider Information | |||||||||
| NPI: | 1841651908 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ARCHULETTA | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | RDH | ||||||||
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| 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 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2016 | ||||||||
| LastUpdateDate: | 04/03/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | DH.000903382 | CO | Y | Dental Providers | Dental Hygienist |
ID Information
| ID | Type | State | Issuer | Description | 69550182 | 05 | CO | MEDICAID |