Provider Demographics
NPI:1508030750
Name:ORAL AND MAXILLOFACIAL SURGERY OF LONGMONT LLC
Entity Type:Organization
Organization Name:ORAL AND MAXILLOFACIAL SURGERY OF LONGMONT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:SQUIRE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-772-8585
Mailing Address - Street 1:1361 FRANCIS STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501
Mailing Address - Country:US
Mailing Address - Phone:303-772-8585
Mailing Address - Fax:303-776-4895
Practice Address - Street 1:1361 FRANCIS STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501
Practice Address - Country:US
Practice Address - Phone:303-772-8585
Practice Address - Fax:303-776-4895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8762122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty