Healthcare Provider Details

I. General information

NPI: 1679037675
Provider Name (Legal Business Name): ORTHODONTICS OF SOUTHWEST COLORADO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2019
Last Update Date: 02/04/2019
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

4760 N BUTLER AVE STE B
FARMINGTON NM
87401-0816
US

V. Phone/Fax

Practice location:
  • Phone: 970-565-3531
  • Fax:
Mailing address:
  • Phone: 505-592-0482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: AMANDA SALAZAR
Title or Position: BILLING
Credential:
Phone: 505-592-0482