Provider Demographics
NPI:1114337136
Name:EXCELLENCE IN ORAL & MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:EXCELLENCE IN ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VIKKI
Authorized Official - Middle Name:
Authorized Official - Last Name:BIERNACKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-592-9222
Mailing Address - Street 1:1755 TELSTAR DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-1016
Mailing Address - Country:US
Mailing Address - Phone:719-592-9222
Mailing Address - Fax:719-592-9682
Practice Address - Street 1:1755 TELSTAR DR
Practice Address - Street 2:SUITE 210
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-1016
Practice Address - Country:US
Practice Address - Phone:719-592-9222
Practice Address - Fax:719-592-9682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-29
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO67091223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty