Provider Demographics
NPI:1831332857
Name:ROCKY MOUNTAIN ORAL AND MAXILLOFACIAL SURGERY
Entity type:Organization
Organization Name:ROCKY MOUNTAIN ORAL AND MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/ORAL SURGEON
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MS
Authorized Official - Phone:303-758-6850
Mailing Address - Street 1:6850 E HAMPDEN AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80224-3024
Mailing Address - Country:US
Mailing Address - Phone:303-758-6850
Mailing Address - Fax:303-758-0729
Practice Address - Street 1:6850 E HAMPDEN AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80224-3024
Practice Address - Country:US
Practice Address - Phone:303-758-6850
Practice Address - Fax:303-758-0729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-07
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO98039768Medicaid