Healthcare Provider Details

I. General information

NPI: 1578706651
Provider Name (Legal Business Name): BLUE RIVER ORAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2009
Last Update Date: 04/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 NORTH TEN MILE DRIVE SUITE E 11
FRISCO CO
80443-4998
US

IV. Provider business mailing address

PO BOX 4998
FRISCO CO
80443-4998
US

V. Phone/Fax

Practice location:
  • Phone: 970-668-1314
  • Fax: 970-668-1057
Mailing address:
  • Phone: 970-668-1314
  • Fax: 970-668-1057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number8755
License Number StateCO

VIII. Authorized Official

Name: DR. KARL L H HEGGLAND
Title or Position: OWNER
Credential: DDS
Phone: 970-668-1314