Provider Demographics
NPI:1225435381
Name:ROOT GROOVE, PLLC
Entity Type:Organization
Organization Name:ROOT GROOVE, PLLC
Other - Org Name:GOLD RUSH DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-352-6633
Mailing Address - Street 1:P.O. BOX 296
Mailing Address - Street 2:
Mailing Address - City:CRIPPLE CREEK
Mailing Address - State:CO
Mailing Address - Zip Code:80813
Mailing Address - Country:US
Mailing Address - Phone:719-689-3565
Mailing Address - Fax:
Practice Address - Street 1:1101 TELLER COUNTY ROAD 1
Practice Address - Street 2:
Practice Address - City:CRIPPLE CREEK
Practice Address - State:CO
Practice Address - Zip Code:80813
Practice Address - Country:US
Practice Address - Phone:719-689-3565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-04
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO102451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty