1205045846 NPI number — WOODMEN CREEK DENTAL PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205045846 NPI number — WOODMEN CREEK DENTAL PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOODMEN CREEK DENTAL PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ROTA ADVANCED DENTAL CARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205045846
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1750 TELSTAR DR
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80920-1047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-598-1224
Provider Business Mailing Address Fax Number:
719-531-9430

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1750 TELSTAR DR
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80920-1047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-598-1224
Provider Business Practice Location Address Fax Number:
719-531-9430
Provider Enumeration Date:
05/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ROTA
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
A
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
719-598-1224

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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