Provider Demographics
NPI:1659755338
Name:COLORADO SPRINGS ORAL AND FACIAL SURGERY
Entity Type:Organization
Organization Name:COLORADO SPRINGS ORAL AND FACIAL SURGERY
Other - Org Name:AFFILIATES IN ORAL AND MAXILLOFACIAL SURGERY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:RECEPTION
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:K
Authorized Official - Last Name:OSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-597-4060
Mailing Address - Street 1:3100 N ACADEMY BLVD
Mailing Address - Street 2:#213
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5321
Mailing Address - Country:US
Mailing Address - Phone:719-597-4060
Mailing Address - Fax:719-574-2140
Practice Address - Street 1:3100 N ACADEMY BLVD
Practice Address - Street 2:#213
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-5321
Practice Address - Country:US
Practice Address - Phone:719-597-4060
Practice Address - Fax:719-574-2140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO107591223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty