Healthcare Provider Details

I. General information

NPI: 1386097665
Provider Name (Legal Business Name): CORTEZ ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2016
Last Update Date: 07/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S MAPLE ST
CORTEZ CO
81321-3562
US

IV. Provider business mailing address

101 S MAPLE ST
CORTEZ CO
81321-3562
US

V. Phone/Fax

Practice location:
  • Phone: 970-565-3531
  • Fax:
Mailing address:
  • Phone: 970-565-3531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberCOLO6144
License Number StateCO

VIII. Authorized Official

Name: ALAN B SCHAFER
Title or Position: ORTHODONTIST/ OWNER
Credential: M.S.D., D.M.D.
Phone: 970-565-3531