Provider Demographics
NPI:1407205461
Name:NORTHERN COLORADO ENDODONTICS
Entity Type:Organization
Organization Name:NORTHERN COLORADO ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:970-229-1404
Mailing Address - Street 1:630 15TH AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-2700
Mailing Address - Country:US
Mailing Address - Phone:720-494-9363
Mailing Address - Fax:720-494-9364
Practice Address - Street 1:630 15TH AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-2700
Practice Address - Country:US
Practice Address - Phone:720-494-9363
Practice Address - Fax:720-494-9364
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHERN COLORADO ENDODONTICS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO73821223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty