Provider Demographics
NPI:1962877795
Name:LONGMONT MODERN DENTISTRY AND ORTHODONTICS, LLP
Entity type:Organization
Organization Name:LONGMONT MODERN DENTISTRY AND ORTHODONTICS, LLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SYMON
Authorized Official - Middle Name:B
Authorized Official - Last Name:STANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:720-907-8770
Mailing Address - Street 1:17000 RED HILL AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5626
Mailing Address - Country:US
Mailing Address - Phone:714-845-8890
Mailing Address - Fax:949-474-1495
Practice Address - Street 1:1234 S HOVER ST
Practice Address - Street 2:100
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-7957
Practice Address - Country:US
Practice Address - Phone:720-907-8770
Practice Address - Fax:720-891-4164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-04
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty