MEDICARE: ALPINE DT 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	1223X2210X	Orofacial Pain Dentistry
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)

General Provider Information

NPI Number	:	1326775800
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALPINE DT FORT COLLINS LLC

Provider Business Mailing Address
First Line	:	950 S TAFT HILL RD
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80521-3230
Country	:	US
Telephone Number	:	970-484-5297
Fax Number	:

Provider Business Practice Location Address
First Line	:	950 S TAFT HILL RD
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80521-3230
Country	:	US
Telephone Number	:	970-484-5297
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	DR. MESA ROTH
Credential	:	DDS
Telephone Number	:	970-484-5297

Provider Enumeration Date	:	08/04/2022
Last Update Date	:	08/04/2022

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