Provider Demographics
NPI:1053690651
Name:WINDSOR PEDIATRIC DENTISTRY PLLC
Entity type:Organization
Organization Name:WINDSOR PEDIATRIC DENTISTRY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JILL
Authorized Official - Middle Name:MACKENZIE
Authorized Official - Last Name:SHONKA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-674-3247
Mailing Address - Street 1:1576 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80550
Mailing Address - Country:US
Mailing Address - Phone:970-674-3247
Mailing Address - Fax:970-460-0865
Practice Address - Street 1:1299 MAIN ST UNIT C
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-5918
Practice Address - Country:US
Practice Address - Phone:970-674-3247
Practice Address - Fax:970-460-0865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-12
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO103461223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty