Healthcare Provider Details

I. General information

NPI: 1184638736
Provider Name (Legal Business Name): NORTHERN COLORADO ENDODONTICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 08/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 WHALERS WAY SUITE 300
FT COLLINS CO
80525
US

IV. Provider business mailing address

3744 S TIMBERLINE RD SUITE 101
FORT COLLINS CO
80525-4333
US

V. Phone/Fax

Practice location:
  • Phone: 970-229-1404
  • Fax: 970-229-1422
Mailing address:
  • Phone: 970-229-1404
  • Fax: 970-229-1422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number7382
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number7256
License Number StateCO

VII. Legacy identifiers

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

VIII. Authorized Official

Name: BRADLEY DAVID LEVALLEY
Title or Position: PRESIDENT
Credential: DDS MS
Phone: 970-229-1404