Provider Demographics
NPI:1295179554
Name:JOSEPH R. FUNDERBURK DDS PROFESSIONAL LLC
Entity Type:Organization
Organization Name:JOSEPH R. FUNDERBURK DDS PROFESSIONAL LLC
Other - Org Name:GRAND JUNCTION ORAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:R
Authorized Official - Last Name:FUNDERBURK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-241-2820
Mailing Address - Street 1:613 25 ROAD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81505-3607
Mailing Address - Country:US
Mailing Address - Phone:970-241-2820
Mailing Address - Fax:970-248-9553
Practice Address - Street 1:613 25 ROAD
Practice Address - Street 2:SUITE 1
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-3607
Practice Address - Country:US
Practice Address - Phone:970-241-2820
Practice Address - Fax:970-248-9553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-17
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO106761223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty