Healthcare Provider Details

I. General information

NPI: 1225564297
Provider Name (Legal Business Name): EVERGREEN ORAL AND MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28000 MEADOW DR UNIT 110
EVERGREEN CO
80439-8395
US

IV. Provider business mailing address

28000 MEADOW DR UNIT 110
EVERGREEN CO
80439-8395
US

V. Phone/Fax

Practice location:
  • Phone: 720-990-5500
  • Fax: 720-990-5501
Mailing address:
  • Phone: 720-990-5500
  • Fax: 720-990-5501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDEN.00202720
License Number StateCO

VIII. Authorized Official

Name: JONATHON JUNDT
Title or Position: OWNER / SURGEON
Credential: DDS, MD
Phone: 720-990-5500