Provider Demographics
NPI:1144498999
Name:PEDIATRIC DENTISTRY OF THE ROCKIES PLLC
Entity type:Organization
Organization Name:PEDIATRIC DENTISTRY OF THE ROCKIES PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:VAN TASSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-484-4104
Mailing Address - Street 1:4609 S TIMBERLINE RD
Mailing Address - Street 2:SUITE 103B
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3170
Mailing Address - Country:US
Mailing Address - Phone:970-484-4104
Mailing Address - Fax:970-484-5245
Practice Address - Street 1:4609 S TIMBERLINE RD
Practice Address - Street 2:SUITE 103B
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3170
Practice Address - Country:US
Practice Address - Phone:970-484-4104
Practice Address - Fax:970-484-5245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO91971223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO82906505Medicaid