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General NPI Number Information
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NPI Number | 1053811463
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Entity Type | Organization
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Legal Business Name | SOUTH GREELEY, PROF. LLC
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Dates
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Enumeration Date | 02/13/2018
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Last Update Date | 02/13/2018
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Provider Practice Location Address
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Address Line | 2716 11TH AVE
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City | GREELEY
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State | CO
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Zip | 80631-8443
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Country | US
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Telephone | 970-673-4310
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Fax |
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Provider Business Mailing Address
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Address Line | 2716 11TH AVE
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City | GREELEY
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State | CO
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Zip | 80631-8443
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Country | US
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Telephone | 970-673-4310
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Fax |
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | JARUM BOYER
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Credential | DMD
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Telephone | 970-673-4310
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 10437
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 10703
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License Number State | CO
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 9766
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License Number State | CO
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