Healthcare Provider Details

I. General information

NPI: 1144498999
Provider Name (Legal Business Name): PEDIATRIC DENTISTRY OF THE ROCKIES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2008
Last Update Date: 10/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4609 S TIMBERLINE RD SUITE 103B
FORT COLLINS CO
80528-3170
US

IV. Provider business mailing address

4609 S TIMBERLINE RD SUITE 103B
FORT COLLINS CO
80528-3170
US

V. Phone/Fax

Practice location:
  • Phone: 970-484-4104
  • Fax: 970-484-5245
Mailing address:
  • Phone: 970-484-4104
  • Fax: 970-484-5245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number9197
License Number StateCO

VII. Legacy identifiers

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

# 1
Identifier82906505
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name: KEITH ALLEN VAN TASSELL
Title or Position: PRESIDENT/OWNER
Credential:
Phone: 970-484-4104