Provider Demographics
NPI:1962401216
Name:GREELEY ORTHODONTIC CENTER
Entity type:Organization
Organization Name:GREELEY ORTHODONTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:KLOBERDANZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS/MS
Authorized Official - Phone:970-330-2500
Mailing Address - Street 1:2021 CLUBHOUSE DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-3667
Mailing Address - Country:US
Mailing Address - Phone:970-330-2500
Mailing Address - Fax:
Practice Address - Street 1:2021 CLUBHOUSE DR
Practice Address - Street 2:SUITE 110
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-3667
Practice Address - Country:US
Practice Address - Phone:970-330-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5941223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty