Healthcare Provider Details

I. General information

NPI: 1235960394
Provider Name (Legal Business Name): DENTAL SPECIALISTS OF FORT COLLINS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2024
Last Update Date: 08/12/2024
Certification Date: 08/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 JOHN F KENNEDY PKWY UNIT E
FORT COLLINS CO
80525-3074
US

IV. Provider business mailing address

11005 S PARKER RD
PARKER CO
80134-7441
US

V. Phone/Fax

Practice location:
  • Phone: 970-673-7900
  • Fax:
Mailing address:
  • Phone: 720-522-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State

VIII. Authorized Official

Name: RON BERGLOFF
Title or Position: BUSINESS PARTNER
Credential:
Phone: 720-431-6060