Healthcare Provider Details

I. General information

NPI: 1043373004
Provider Name (Legal Business Name): CHERRY CREEK ORAL & MAXILLOFACIAL SURGERY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3955 E EXPOSITION AVE SUITE 520
DENVER CO
80209-5000
US

IV. Provider business mailing address

3955 E EXPOSITION AVE SUITE 520
DENVER CO
80209-5000
US

V. Phone/Fax

Practice location:
  • Phone: 303-777-1603
  • Fax:
Mailing address:
  • Phone: 303-777-1603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7506
License Number StateCO

VIII. Authorized Official

Name: DR. CLYDE E WAGGONER
Title or Position: PRESIDENT
Credential: DMD
Phone: 303-777-1603