Provider Demographics
NPI:1518561364
Name:CHEYENNE MOUNTAIN ORAL SURGERY PC
Entity Type:Organization
Organization Name:CHEYENNE MOUNTAIN ORAL SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:RENEHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-540-6350
Mailing Address - Street 1:640 SOUTHPOINTE CT STE 150
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-3884
Mailing Address - Country:US
Mailing Address - Phone:719-540-6350
Mailing Address - Fax:719-527-9487
Practice Address - Street 1:640 SOUTHPOINTE CT STE 150
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3884
Practice Address - Country:US
Practice Address - Phone:719-540-6350
Practice Address - Fax:719-527-9487
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHEYENNE MOUNTAIN ORAL SURGERY PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty