Provider Demographics
NPI:1043480452
Name:GLENWOOD ORAL SURGERY, P.C.
Entity type:Organization
Organization Name:GLENWOOD ORAL SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:HALTOM
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-945-9644
Mailing Address - Street 1:406 SOUTH HYLAND PARK DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:GLENWOOD SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81601
Mailing Address - Country:US
Mailing Address - Phone:970-945-9644
Mailing Address - Fax:970-945-0760
Practice Address - Street 1:406 SOUTH HYLAND PARK DR
Practice Address - Street 2:SUITE B
Practice Address - City:GLENWOOD SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81601
Practice Address - Country:US
Practice Address - Phone:970-945-9644
Practice Address - Fax:970-945-0760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COHD104468261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery