Healthcare Provider Details

I. General information

NPI: 1326775800
Provider Name (Legal Business Name): ALPINE DT FORT COLLINS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2022
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 S TAFT HILL RD
FORT COLLINS CO
80521-3230
US

IV. Provider business mailing address

950 S TAFT HILL RD
FORT COLLINS CO
80521-3230
US

V. Phone/Fax

Practice location:
  • Phone: 970-484-5297
  • Fax:
Mailing address:
  • Phone: 970-484-5297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. MESA ROTH
Title or Position: PARTNER
Credential: DDS
Phone: 970-484-5297