Provider Demographics
NPI:1326775800
Name:ALPINE DT FORT COLLINS LLC
Entity Type:Organization
Organization Name:ALPINE DT FORT COLLINS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MESA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-484-5297
Mailing Address - Street 1:950 S TAFT HILL RD
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80521-3230
Mailing Address - Country:US
Mailing Address - Phone:970-484-5297
Mailing Address - Fax:
Practice Address - Street 1:950 S TAFT HILL RD
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80521-3230
Practice Address - Country:US
Practice Address - Phone:970-484-5297
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X2210XDental ProvidersDentistOrofacial PainGroup - Multi-Specialty