Healthcare Provider Details

I. General information

NPI: 1043480452
Provider Name (Legal Business Name): GLENWOOD ORAL SURGERY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2008
Last Update Date: 03/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 SOUTH HYLAND PARK DR SUITE B
GLENWOOD SPRINGS CO
81601
US

IV. Provider business mailing address

406 SOUTH HYLAND PARK DR SUITE B
GLENWOOD SPRINGS CO
81601
US

V. Phone/Fax

Practice location:
  • Phone: 970-945-9644
  • Fax: 970-945-0760
Mailing address:
  • Phone: 970-945-9644
  • Fax: 970-945-0760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License NumberHD104468
License Number StateCO

VIII. Authorized Official

Name: DR. GEORGE WAYNE HALTOM III
Title or Position: OWNER
Credential: D.D.S.
Phone: 970-945-9644