Healthcare Provider Details

I. General information

NPI: 1215659206
Provider Name (Legal Business Name): FORT COLLINS ORAL & MAXILLOFACIAL SURGERY PARTNERSHIP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2022
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2014 CARIBOU DR STE 100
FORT COLLINS CO
80525-4330
US

IV. Provider business mailing address

2014 CARIBOU DR STE 100
FORT COLLINS CO
80525-4330
US

V. Phone/Fax

Practice location:
  • Phone: 970-225-9555
  • Fax: 970-223-2294
Mailing address:
  • Phone: 970-225-9555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number StateNULL

VIII. Authorized Official

Name: MARK FRANK ORR
Title or Position: GENERAL PARTNER
Credential: MD, DDS
Phone: 970-225-9555