Healthcare Provider Details

I. General information

NPI: 1053811463
Provider Name (Legal Business Name): SOUTH GREELEY, PROF. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2018
Last Update Date: 02/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2716 11TH AVE
GREELEY CO
80631-8443
US

IV. Provider business mailing address

2716 11TH AVE
GREELEY CO
80631-8443
US

V. Phone/Fax

Practice location:
  • Phone: 970-673-4310
  • Fax:
Mailing address:
  • Phone: 970-673-4310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number10437
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number10703
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9766
License Number StateCO

VIII. Authorized Official

Name: JARUM BOYER
Title or Position: DENTIST/OWNER
Credential: DMD
Phone: 970-673-4310