Provider Demographics
NPI:1407167836
Name:CROSSROADS DENTAL
Entity Type:Organization
Organization Name:CROSSROADS DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:FARMER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-776-1480
Mailing Address - Street 1:1520 S HOVER ST STE E-F
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-7959
Mailing Address - Country:US
Mailing Address - Phone:303-776-1480
Mailing Address - Fax:
Practice Address - Street 1:1520 S HOVER ST STE E-F
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-7959
Practice Address - Country:US
Practice Address - Phone:303-776-1480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7850261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental