Provider Demographics
NPI:1053811463
Name:SOUTH GREELEY, PROF. LLC
Entity type:Organization
Organization Name:SOUTH GREELEY, PROF. LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JARUM
Authorized Official - Middle Name:
Authorized Official - Last Name:BOYER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:970-673-4310
Mailing Address - Street 1:2716 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-8443
Mailing Address - Country:US
Mailing Address - Phone:970-673-4310
Mailing Address - Fax:
Practice Address - Street 1:2716 11TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-8443
Practice Address - Country:US
Practice Address - Phone:970-673-4310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-13
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9766122300000X
CO10437122300000X
CO10703122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1720371404OtherNPI
CO50472721Medicaid
CO1285814772OtherNPI
CO49305832Medicaid
CO49032551Medicaid
CO1063555043OtherNPI