Healthcare Provider Details

I. General information

NPI: 1508146630
Provider Name (Legal Business Name): CASTLE ROCK ORAL AND MAXILLOFACIAL SURGERY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2011
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2352 MEADOWS BLVD 205
CASTLE ROCK CO
80109-8406
US

IV. Provider business mailing address

2352 MEADOWS BLVD 205
CASTLE ROCK CO
80109-8406
US

V. Phone/Fax

Practice location:
  • Phone: 303-663-7890
  • Fax: 888-765-9130
Mailing address:
  • Phone: 303-663-7890
  • Fax: 888-765-9130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number10214
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number21512
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number21512
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number10214
License Number StateCO

VIII. Authorized Official

Name: DR. KRISTOPHER LARKIN HART
Title or Position: PRESIDENT
Credential: DDS
Phone: 254-449-6581