Provider Demographics
NPI:1366975765
Name:LONGMONT ORAL, FACIAL & IMPLANT SURGERY
Entity type:Organization
Organization Name:LONGMONT ORAL, FACIAL & IMPLANT SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-772-8870
Mailing Address - Street 1:1551 PROFESSIONAL LN UNIT 260
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-6903
Mailing Address - Country:US
Mailing Address - Phone:303-772-8870
Mailing Address - Fax:303-772-8871
Practice Address - Street 1:1551 PROFESSIONAL LN UNIT 260
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6903
Practice Address - Country:US
Practice Address - Phone:303-772-8870
Practice Address - Fax:303-772-8871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002018411223S0112X
CODEN.000100711223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1386808533OtherNPI
CO1689797243OtherNPI