Provider Demographics
NPI:1679037675
Name:ORTHODONTICS OF SOUTHWEST COLORADO PC
Entity Type:Organization
Organization Name:ORTHODONTICS OF SOUTHWEST COLORADO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:SALAZAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-592-0482
Mailing Address - Street 1:4760 N BUTLER AVE STE B
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-0816
Mailing Address - Country:US
Mailing Address - Phone:505-592-0482
Mailing Address - Fax:
Practice Address - Street 1:101 S MAPLE ST
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-3562
Practice Address - Country:US
Practice Address - Phone:970-565-3531
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-24
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty