Healthcare Provider Details

I. General information

NPI: 1124851464
Provider Name (Legal Business Name): FAMILY DENTAL AND SPECIALISTS OF GREELEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2024
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 W 16TH ST UNIT E
GREELEY CO
80634-6862
US

IV. Provider business mailing address

952 CHIMNEY ROCK RD
HIGHLANDS RANCH CO
80126-2552
US

V. Phone/Fax

Practice location:
  • Phone: 970-673-7900
  • Fax:
Mailing address:
  • Phone: 720-431-6060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: RON BERGLOFF
Title or Position: OWNER
Credential:
Phone: 720-431-6060