Provider Demographics
NPI:1568863223
Name:COLORADO PLAINS ORAL & MAXILLOFACIAL SURGERY P.C.
Entity Type:Organization
Organization Name:COLORADO PLAINS ORAL & MAXILLOFACIAL SURGERY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:BOEDEKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-867-4477
Mailing Address - Street 1:527 W PLATTE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MORGAN
Mailing Address - State:CO
Mailing Address - Zip Code:80701-2654
Mailing Address - Country:US
Mailing Address - Phone:970-768-6869
Mailing Address - Fax:970-867-4499
Practice Address - Street 1:527 W PLATTE AVE
Practice Address - Street 2:
Practice Address - City:FORT MORGAN
Practice Address - State:CO
Practice Address - Zip Code:80701-2654
Practice Address - Country:US
Practice Address - Phone:970-768-6869
Practice Address - Fax:970-867-4499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-11
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10147261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental