Healthcare Provider Details

I. General information

NPI: 1013114230
Provider Name (Legal Business Name): FRONT RANGE OTOLARYNGOLOGY & FACIAL PLASTIC SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 05/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 DRY CREEK DR SUITE 103
LONGMONT CO
80503-7731
US

IV. Provider business mailing address

1325 DRY CREEK DR SUITE 103
LONGMONT CO
80503-7731
US

V. Phone/Fax

Practice location:
  • Phone: 720-494-9111
  • Fax: 720-494-9555
Mailing address:
  • Phone: 720-494-9111
  • Fax: 720-494-9555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number207YS0123X
License Number StateCO

VIII. Authorized Official

Name: DR. KEVIN C CAVANAUGH
Title or Position: OWNER MD
Credential: MD
Phone: 720-494-9111