Healthcare Provider Details

I. General information

NPI: 1396736641
Provider Name (Legal Business Name): RICHARD WILSON LINDEBERG D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 E ELIZABETH ST
FORT COLLINS CO
80524-4044
US

IV. Provider business mailing address

1120 E ELIZABETH ST
FORT COLLINS CO
80524-4044
US

V. Phone/Fax

Practice location:
  • Phone: 970-221-5050
  • Fax: 970-221-5054
Mailing address:
  • Phone: 970-221-5050
  • Fax: 970-221-5054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number617
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: