Healthcare Provider Details

I. General information

NPI: 1346484193
Provider Name (Legal Business Name): COLORADO REGIONAL ORAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2009
Last Update Date: 04/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8025 CLUB CREST DRIVE
ARVADA CO
80005
US

IV. Provider business mailing address

8025 CLUB CREST DRIVE
ARVADA CO
80005
US

V. Phone/Fax

Practice location:
  • Phone: 303-431-0033
  • Fax: 303-431-0507
Mailing address:
  • Phone: 303-431-0033
  • Fax: 303-431-0507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number0796
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0796
License Number StateCO

VIII. Authorized Official

Name: MRS. DIANE M CORONA
Title or Position: OFFICE MANAGER
Credential: LPN
Phone: 303-431-0033