Healthcare Provider Details

I. General information

NPI: 1225588221
Provider Name (Legal Business Name): TRAUMA AND EMERGENCY SUBSPECIALTY SURGEONS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2016
Last Update Date: 10/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1745 SHEA CENTER DR SUITE 400
HIGHLANDS RANCH CO
80129-1537
US

IV. Provider business mailing address

1745 SHEA CENTER DR SUITE 400
HIGHLANDS RANCH CO
80129-1537
US

V. Phone/Fax

Practice location:
  • Phone: 303-774-1974
  • Fax:
Mailing address:
  • Phone: 303-774-1974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number40115
License Number StateCO

VIII. Authorized Official

Name: MR. BRIAN J WILLOUGHBY
Title or Position: SOLE OWNER
Credential: M.D.
Phone: 303-320-5700