=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558051045
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | B & G ORTHODONTICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2023
-----------------------------------------------------
Last Update Date | 05/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 KEN PRATT BLVD STE 208
-----------------------------------------------------
City | LONGMONT
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80501-6455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-833-5550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 KEN PRATT BLVD STE 208
-----------------------------------------------------
City | LONGMONT
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80501-6455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-833-5550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORTHODONTIST
-----------------------------------------------------
Name | GREGORY RAYMOND WERNER
-----------------------------------------------------
Credential | DDS, MS
-----------------------------------------------------
Telephone | 720-833-5550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------