=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891274122
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TIMBERLINE ORTHODONTICS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2018
-----------------------------------------------------
Last Update Date | 08/08/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1424 E HORSETOOTH RD STE 1
-----------------------------------------------------
City | FORT COLLINS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80525-5726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-223-8080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 E 35TH ST
-----------------------------------------------------
City | SCOTTSBLUFF
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 69361-4694
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-314-5132
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BRONSEN SCHLIEP
-----------------------------------------------------
Credential | DDS, MS
-----------------------------------------------------
Telephone | 402-314-5132
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 203592
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------