Healthcare Provider Details

I. General information

NPI: 1619780582
Provider Name (Legal Business Name): HEADACHE & TMJ CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2025
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1243 SHERMAN DR STE 100F
LONGMONT CO
80501-6170
US

IV. Provider business mailing address

1243 SHERMAN DR STE 100F
LONGMONT CO
80501-6170
US

V. Phone/Fax

Practice location:
  • Phone: 720-378-8277
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MEREDITH BURNS
Title or Position: OWNER
Credential:
Phone: 952-297-2287