Provider Demographics
NPI:1225564297
Name:EVERGREEN ORAL AND MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:EVERGREEN ORAL AND MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:JONATHON
Authorized Official - Middle Name:
Authorized Official - Last Name:JUNDT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:720-990-5500
Mailing Address - Street 1:28000 MEADOW DR UNIT 110
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-8395
Mailing Address - Country:US
Mailing Address - Phone:720-990-5500
Mailing Address - Fax:720-990-5501
Practice Address - Street 1:28000 MEADOW DR UNIT 110
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-8395
Practice Address - Country:US
Practice Address - Phone:720-990-5500
Practice Address - Fax:720-990-5501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002027201223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty