Provider Demographics
NPI:1437550050
Name:NORTHERN COLORADO PERIODONTICS
Entity Type:Organization
Organization Name:NORTHERN COLORADO PERIODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-351-6166
Mailing Address - Street 1:4033 BOARDWALK DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-5934
Mailing Address - Country:US
Mailing Address - Phone:970-207-4061
Mailing Address - Fax:970-207-0051
Practice Address - Street 1:3400 W 16TH ST
Practice Address - Street 2:SUITE 5X
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-6862
Practice Address - Country:US
Practice Address - Phone:970-351-6166
Practice Address - Fax:970-673-8732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO83501223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty