Healthcare Provider Details

I. General information

NPI: 1568965812
Provider Name (Legal Business Name): ADVANCED PROSTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 03/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1006 ROBERTSON ST STE 210
FORT COLLINS CO
80524-3920
US

IV. Provider business mailing address

1006 ROBERTSON ST STE 210
FORT COLLINS CO
80524-3920
US

V. Phone/Fax

Practice location:
  • Phone: 970-493-9001
  • Fax:
Mailing address:
  • Phone: 970-493-9001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberD202404
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

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