=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518482199
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORAL & FACIAL SURGERY OF LOVELAND, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2017
-----------------------------------------------------
Last Update Date | 08/04/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3520 E 15TH ST STE 102
-----------------------------------------------------
City | LOVELAND
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80538-8938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-663-6878
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3520 E 15TH ST STE 102
-----------------------------------------------------
City | LOVELAND
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80538-8938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORAL AND FACIAL SURGEON
-----------------------------------------------------
Name | DR. RALPH RICARDO REYNOLDS
-----------------------------------------------------
Credential | DMD, MD
-----------------------------------------------------
Telephone | 970-663-6878
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 7908
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------