Provider Demographics
NPI:1881948651
Name:HIGHLANDS RANCH CENTER FOR AESTHETIC & MAXILLOFACIAL SURGERY
Entity type:Organization
Organization Name:HIGHLANDS RANCH CENTER FOR AESTHETIC & MAXILLOFACIAL SURGERY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:COLM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:303-791-0422
Mailing Address - Street 1:200 W COUNTY LINE RD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80129-2360
Mailing Address - Country:US
Mailing Address - Phone:303-791-0422
Mailing Address - Fax:303-791-0564
Practice Address - Street 1:200 W COUNTY LINE RD
Practice Address - Street 2:SUITE 230
Practice Address - City:HIGHLANDS RANCH
Practice Address - State:CO
Practice Address - Zip Code:80129-2360
Practice Address - Country:US
Practice Address - Phone:303-791-0422
Practice Address - Fax:303-791-0564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-01
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7009122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO45852316Medicaid