1972000933 NPI number — ROCKY MOUNTAIN ROOT CANAL SPECIALIST, PLLC

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 1972000933 NPI number — ROCKY MOUNTAIN ROOT CANAL SPECIALIST, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROCKY MOUNTAIN ROOT CANAL SPECIALIST, PLLC
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:
Provider Other Organization Name Type Code:
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:
1972000933
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 STEWART CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ERIE
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80516-6884
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-916-0381
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13762 COLORADO BLVD UNIT 154
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THORNTON
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80602-6919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-916-0381
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/06/2018

Additional Information

Authorized Official

Authorized Official Last Name:
MCBRIDE
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
KIRK
Authorized Official Title or Position:
OWNER/ENDODONTIST
Authorized Official Telephone Number:
303-916-0381

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X , with the licence number:  DEN.00010233 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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