Provider Demographics
NPI:1134868862
Name:ROGUE RIVER FAMILY DENTAL
Entity type:Organization
Organization Name:ROGUE RIVER FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELLIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:LOOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-443-2387
Mailing Address - Street 1:2 N MONROE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-1228
Mailing Address - Country:US
Mailing Address - Phone:616-866-7720
Mailing Address - Fax:
Practice Address - Street 1:2 N MONROE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-1228
Practice Address - Country:US
Practice Address - Phone:616-866-7720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental