Healthcare Provider Details

I. General information

NPI: 1184767816
Provider Name (Legal Business Name): RONALD D VINCENT D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 GLENWOOD AVE
GRAND JCT CO
81501-7579
US

IV. Provider business mailing address

306 GLENWOOD AVE
GRAND JCT CO
81501-7579
US

V. Phone/Fax

Practice location:
  • Phone: 970-242-6623
  • Fax: 970-242-6627
Mailing address:
  • Phone: 970-242-6623
  • Fax: 970-242-6627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3450
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: