Healthcare Provider Details

I. General information

NPI: 1760771695
Provider Name (Legal Business Name): FORT COLLINS DENTAL GROUP, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2011
Last Update Date: 03/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 E HARMONY RD STE 103
FORT COLLINS CO
80528-3427
US

IV. Provider business mailing address

2860 MICHELLE FL 2
IRVINE CA
92606-1008
US

V. Phone/Fax

Practice location:
  • Phone: 970-282-8877
  • Fax: 970-226-1326
Mailing address:
  • Phone: 714-368-2077
  • Fax: 714-368-2092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. CHARLES F RODGERS
Title or Position: OWNER DOCTOR
Credential: DDS
Phone: 970-282-8877