1134447972 NPI number — IMPLANT AND ORAL SURGERY OF COLORADO PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134447972 NPI number — IMPLANT AND ORAL SURGERY OF COLORADO PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IMPLANT AND ORAL SURGERY OF COLORADO PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134447972
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
755 S PERRY ST
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
CASTLE ROCK
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80104-1901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-660-5651
Provider Business Mailing Address Fax Number:
303-660-1582

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3000 UNITED FOUNDERS BLVD
Provider Second Line Business Practice Location Address:
STE 237
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73112-3958
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-848-7974
Provider Business Practice Location Address Fax Number:
405-848-0033
Provider Enumeration Date:
05/04/2010

Additional Information

Authorized Official

Authorized Official Last Name:
DRESHER
Authorized Official First Name:
KATHY
Authorized Official Middle Name:
Authorized Official Title or Position:
VP OF BILLING
Authorized Official Telephone Number:
405-848-7974

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  8089 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02047637 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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