Provider Demographics
NPI:1578706651
Name:BLUE RIVER ORAL SURGERY
Entity Type:Organization
Organization Name:BLUE RIVER ORAL SURGERY
Other - Org Name:ALPINE O.M.S.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KARL
Authorized Official - Middle Name:L H
Authorized Official - Last Name:HEGGLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-668-1314
Mailing Address - Street 1:PO BOX 4998
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:CO
Mailing Address - Zip Code:80443-4998
Mailing Address - Country:US
Mailing Address - Phone:970-668-1314
Mailing Address - Fax:970-668-1057
Practice Address - Street 1:975 NORTH TEN MILE DRIVE
Practice Address - Street 2:SUITE E 11
Practice Address - City:FRISCO
Practice Address - State:CO
Practice Address - Zip Code:80443-4998
Practice Address - Country:US
Practice Address - Phone:970-668-1314
Practice Address - Fax:970-668-1057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-20
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8755261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery