Provider Demographics
NPI:1447384532
Name:AFFILIATES IN ORAL & MAXILLOFACIAL SURGERY,P.C.
Entity Type:Organization
Organization Name:AFFILIATES IN ORAL & MAXILLOFACIAL SURGERY,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:BERWICK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-597-4060
Mailing Address - Street 1:3100 N ACADEMY BLVD
Mailing Address - Street 2:SUITE 213
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5321
Mailing Address - Country:US
Mailing Address - Phone:719-597-4060
Mailing Address - Fax:719-574-2140
Practice Address - Street 1:3100 N ACADEMY BLVD
Practice Address - Street 2:SUITE 213
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-5321
Practice Address - Country:US
Practice Address - Phone:719-597-4060
Practice Address - Fax:719-574-2140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO72021223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO76159361Medicaid