Provider Demographics
NPI:1306396551
Name:ROTA ADVANCED DENTAL CARE
Entity Type:Organization
Organization Name:ROTA ADVANCED DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-598-1224
Mailing Address - Street 1:6210 WOODMEN PARK VW
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80923-2616
Mailing Address - Country:US
Mailing Address - Phone:719-598-1224
Mailing Address - Fax:719-531-9430
Practice Address - Street 1:6210 WOODMEN PARK VW
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80923-2616
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:2016-10-12
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO104340122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty