Healthcare Provider Details

I. General information

NPI: 1538449558
Provider Name (Legal Business Name): DERMATOLOGY CENTER OF THE ROCKIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2011
Last Update Date: 08/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 PROFESSIONAL LN 135
LONGMONT CO
80501-6972
US

IV. Provider business mailing address

1551 PROFESSIONAL LN 135
LONGMONT CO
80501-6972
US

V. Phone/Fax

Practice location:
  • Phone: 303-532-2810
  • Fax: 303-532-2816
Mailing address:
  • Phone: 303-532-2810
  • Fax: 303-532-2816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number StateCO

VIII. Authorized Official

Name: MS. KRISTIN M BAIRD
Title or Position: PRESIDENT
Credential: M.D.
Phone: 303-532-2810