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General NPI Number Information
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NPI Number | 1184377392
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Entity Type | Organization
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Legal Business Name | PAGOSA PEAK FAMILY DENTISTRY, PLLC
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Dates
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Enumeration Date | 01/28/2022
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Last Update Date | 01/28/2022
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Provider Practice Location Address
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Address Line | 228 VILLAGE DR
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City | PAGOSA SPRINGS
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State | CO
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Zip | 81147-8308
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Country | US
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Telephone | 216-374-5693
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Fax |
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Provider Business Mailing Address
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Address Line | 115 HAREBELL DR
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City | PAGOSA SPRINGS
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State | CO
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Zip | 81147-7721
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Country | US
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Telephone | 216-374-5693
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. PETER ROUKEMA
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Credential | DMD
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Telephone | 216-374-5693
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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