Provider Demographics
NPI:1205045846
Name:WOODMEN CREEK DENTAL PC
Entity Type:Organization
Organization Name:WOODMEN CREEK DENTAL PC
Other - Org Name:ROTA ADVANCED DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROTA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:719-598-1224
Mailing Address - Street 1:1750 TELSTAR DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-1047
Mailing Address - Country:US
Mailing Address - Phone:719-598-1224
Mailing Address - Fax:719-531-9430
Practice Address - Street 1:1750 TELSTAR DR
Practice Address - Street 2:SUITE 200
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-1047
Practice Address - Country:US
Practice Address - Phone:719-598-1224
Practice Address - Fax:719-531-9430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO6523140001Medicare NSC