Provider Demographics
NPI:1497915854
Name:VAIL ORAL AND MAXILLOFACIAL RADIOLOGY, LLC
Entity Type:Organization
Organization Name:VAIL ORAL AND MAXILLOFACIAL RADIOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:GAREL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-569-3055
Mailing Address - Street 1:PO BOX 4507
Mailing Address - Street 2:0105 EDWARDS VILLAGE BLVD #C-205
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-4507
Mailing Address - Country:US
Mailing Address - Phone:970-569-3055
Mailing Address - Fax:970-569-3057
Practice Address - Street 1:105 EDWARDS VILLAGE BLVD # C-205
Practice Address - Street 2:
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632-9914
Practice Address - Country:US
Practice Address - Phone:970-569-3055
Practice Address - Fax:970-569-3057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO104546261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental