| Pediatric Dentistry Of The Rockies | |
|
4609 S Timberline Rd Suite 103b Fort Collins CO 80528-3170 | |
| (970) 484-4104 | |
| (970) 484-5245 |
| Full Name | Pediatric Dentistry Of The Rockies |
|---|---|
| Speciality | Dentist - Pediatric Dentistry |
| Location | 4609 S Timberline Rd, Fort Collins, Colorado |
| Authorized Official Name and Position | Keith Allen Van Tassell (PRESIDENT/OWNER) |
| Authorized Official Contact | 9704844104 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Pediatric Dentistry Of The Rockies 4609 S Timberline Rd Suite 103b Fort Collins CO 80528-3170 Ph: (970) 484-4104 | Pediatric Dentistry Of The Rockies 4609 S Timberline Rd Suite 103b Fort Collins CO 80528-3170 Ph: (970) 484-4104 |
| NPI Number | 1144498999 |
|---|---|
| Provider Enumeration Date | 02/14/2008 |
| Last Update Date | 10/23/2018 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1144498999 | NPI | - | NPPES |
| 82906505 | Medicaid | CO |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223P0221X | Dentist - Pediatric Dentistry | 9197 (Colorado) | Primary |
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