Healthcare Provider Details

I. General information

NPI: 1962401216
Provider Name (Legal Business Name): GREELEY ORTHODONTIC CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 CLUBHOUSE DR SUITE 110
GREELEY CO
80634-3667
US

IV. Provider business mailing address

2021 CLUBHOUSE DR SUITE 110
GREELEY CO
80634-3667
US

V. Phone/Fax

Practice location:
  • Phone: 970-330-2500
  • Fax:
Mailing address:
  • Phone: 970-330-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number594
License Number StateCO

VIII. Authorized Official

Name: DR. GARY JOSEPH KLOBERDANZ
Title or Position: PRESIDENT
Credential: DDS/MS
Phone: 970-330-2500