Provider Demographics
NPI:1770091720
Name:ALTITUDE ORAL AND FACIAL COSMETIC SURGERY LONE TREE, PLLC
Entity type:Organization
Organization Name:ALTITUDE ORAL AND FACIAL COSMETIC SURGERY LONE TREE, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:FANGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:614-354-7468
Mailing Address - Street 1:3596 BIRCH AVE
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-9615
Mailing Address - Country:US
Mailing Address - Phone:614-354-7468
Mailing Address - Fax:
Practice Address - Street 1:10375 PARK MEADOWS DR STE 150
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-6755
Practice Address - Country:US
Practice Address - Phone:303-792-2828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FANGMAN ORAL AND FACIAL SURGERY PROFESSIONAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-01-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0202239261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1952791964Medicaid
NY1609027556OtherINDIVIDUAL NPI