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General NPI Number Information
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NPI Number | 1417281387
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Entity Type | Organization
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Legal Business Name | CENTERRA ORTHODONTICS
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Dates
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Enumeration Date | 09/25/2009
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Last Update Date | 09/25/2009
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Provider Practice Location Address
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Address Line | 1825 56TH AVE STE A
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City | GREELEY
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State | CO
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Zip | 80634-3028
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Country | US
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Telephone | 970-330-5363
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Fax |
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Provider Business Mailing Address
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Address Line | 1825 56TH AVE STE A
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City | GREELEY
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State | CO
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Zip | 80634-3028
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Country | US
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Telephone | 970-330-5363
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Fax |
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | DR. BRADLEY EUGENE GOINGS
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Credential | DDS
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Telephone | 970-330-5363
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 8834
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License Number State | CO
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