Provider Demographics
NPI:1326149915
Name:COLORADO WEST ENDODONTICS LLC
Entity Type:Organization
Organization Name:COLORADO WEST ENDODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:NORTHUP
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-242-9088
Mailing Address - Street 1:1190 BOOKCLIFF AVE
Mailing Address - Street 2:#204
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501
Mailing Address - Country:US
Mailing Address - Phone:970-242-9088
Mailing Address - Fax:970-257-0255
Practice Address - Street 1:1190 BOOKCLIFF AVE
Practice Address - Street 2:#204
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501
Practice Address - Country:US
Practice Address - Phone:970-242-9088
Practice Address - Fax:970-257-0255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO71751223E0200X
CO71161223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
822910OtherUNITED CONCORDIA INS