Provider Demographics
NPI:1972981421
Name:HIGH PLAINS ORTHODONTICS PLLC
Entity Type:Organization
Organization Name:HIGH PLAINS ORTHODONTICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:WILHELM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-867-9464
Mailing Address - Street 1:109 W 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MORGAN
Mailing Address - State:CO
Mailing Address - Zip Code:80701-2011
Mailing Address - Country:US
Mailing Address - Phone:970-867-9464
Mailing Address - Fax:970-867-9465
Practice Address - Street 1:109 W 9TH AVE
Practice Address - Street 2:
Practice Address - City:FORT MORGAN
Practice Address - State:CO
Practice Address - Zip Code:80701-2011
Practice Address - Country:US
Practice Address - Phone:970-867-9464
Practice Address - Fax:970-867-9465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-15
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31461223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO46931368Medicaid