Provider Demographics
NPI:1598188450
Name:FORT MORGAN ORTHODONTIC CENTER
Entity Type:Organization
Organization Name:FORT MORGAN ORTHODONTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:KLOBERDANZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-542-2500
Mailing Address - Street 1:531 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:970-542-2500
Mailing Address - Fax:
Practice Address - Street 1:531 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:970-542-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-29
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO005941223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty