MEDICARE: ALPINE WEST FORT COLLINS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	8319	CO

General Provider Information

NPI Number	:	1255706115
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALPINE WEST FORT COLLINS LLC

Provider Business Mailing Address
First Line	:	718 S COLLEGE AVE
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-3301
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1015 S TAFT HILL RD
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80521-4240
Country	:	US
Telephone Number	:	970-482-6034
Fax Number	:

Authorized Official
Title or Position	:	MEMEBER
Name	:	MICHAEL MCDILL
Credential	:
Telephone Number	:	970-484-5297

Provider Enumeration Date	:	12/03/2015
Last Update Date	:	12/03/2015

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