Provider Demographics
NPI:1396020657
Name:SQUIRE ORAL, FACIAL & DENTAL IMPLANT SURGERY
Entity Type:Organization
Organization Name:SQUIRE ORAL, FACIAL & DENTAL IMPLANT SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTAL FACILITATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:K
Authorized Official - Last Name:MATZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-772-8585
Mailing Address - Street 1:1325 HOVER ST. STE. 101
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501
Mailing Address - Country:US
Mailing Address - Phone:303-772-8585
Mailing Address - Fax:
Practice Address - Street 1:1361 FRANCIS ST. STE. 101
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501
Practice Address - Country:US
Practice Address - Phone:303-772-8585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO87621223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty