Provider Demographics
NPI:1063900231
Name:COLORADO MAXILLOFACIAL AND ORAL SURGEONS
Entity type:Organization
Organization Name:COLORADO MAXILLOFACIAL AND ORAL SURGEONS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:FACY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:719-555-1212
Mailing Address - Street 1:4105 BRIARGATE PKWY STE 240
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7844
Mailing Address - Country:US
Mailing Address - Phone:719-310-7670
Mailing Address - Fax:719-666-1212
Practice Address - Street 1:4105 BRIARGATE PKWY STE 240
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7844
Practice Address - Country:US
Practice Address - Phone:719-310-7670
Practice Address - Fax:719-666-1212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00008955204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02239507Medicaid