Healthcare Provider Details

I. General information

NPI: 1225486293
Provider Name (Legal Business Name): EASTERN PLAINS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2016
Last Update Date: 05/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 FIFTH ST.
CALHAN CO
80808
US

IV. Provider business mailing address

P.O. BOX 41
CALHAN CO
80808
US

V. Phone/Fax

Practice location:
  • Phone: 719-347-3212
  • Fax:
Mailing address:
  • Phone: 719-347-3212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9448
License Number StateCO

VIII. Authorized Official

Name: DR. RONALD P. RONCO
Title or Position: DENTIST
Credential: DMD
Phone: 719-347-3212