Provider Demographics
NPI:1184638736
Name:NORTHERN COLORADO ENDODONTICS PC
Entity Type:Organization
Organization Name:NORTHERN COLORADO ENDODONTICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:LEVALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:970-229-1404
Mailing Address - Street 1:3744 S TIMBERLINE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-4333
Mailing Address - Country:US
Mailing Address - Phone:970-229-1404
Mailing Address - Fax:970-229-1422
Practice Address - Street 1:730 WHALERS WAY
Practice Address - Street 2:SUITE 300
Practice Address - City:FT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525
Practice Address - Country:US
Practice Address - Phone:970-229-1404
Practice Address - Fax:970-229-1422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO73821223E0200X
CO72561223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty