Healthcare Provider Details

I. General information

NPI: 1558051045
Provider Name (Legal Business Name): B & G ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2023
Last Update Date: 05/10/2023
Certification Date: 05/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 KEN PRATT BLVD STE 208
LONGMONT CO
80501-6455
US

IV. Provider business mailing address

700 KEN PRATT BLVD STE 208
LONGMONT CO
80501-6455
US

V. Phone/Fax

Practice location:
  • Phone: 720-833-5550
  • Fax:
Mailing address:
  • Phone: 720-833-5550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: GREGORY RAYMOND WERNER
Title or Position: ORTHODONTIST
Credential: DDS, MS
Phone: 720-833-5550