Provider Demographics
NPI:1093469447
Name:FANGMAN ORAL AND FACIAL SURGERY PROFESSIONAL LLC
Entity Type:Organization
Organization Name:FANGMAN ORAL AND FACIAL SURGERY PROFESSIONAL LLC
Other - Org Name:ALTITUDE ORAL AND FACIAL SURGERY PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FANGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:720-328-4990
Mailing Address - Street 1:5600 W 44TH AVE UNIT 100
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80212-7339
Mailing Address - Country:US
Mailing Address - Phone:720-328-4990
Mailing Address - Fax:720-328-4994
Practice Address - Street 1:5600 W 44TH AVE UNIT 100
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80212-7339
Practice Address - Country:US
Practice Address - Phone:720-328-4990
Practice Address - Fax:720-328-4994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-04
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1609027556OtherINDIVIDUAL NPI
CO1952791964Medicaid