Provider Demographics
NPI:1346509429
Name:SHADOW ROCK DENTIST LLC
Entity Type:Organization
Organization Name:SHADOW ROCK DENTIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VIKASH
Authorized Official - Middle Name:
Authorized Official - Last Name:KANCHANLAL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:303-257-8237
Mailing Address - Street 1:734 WILCOX ST
Mailing Address - Street 2:#200
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-1709
Mailing Address - Country:US
Mailing Address - Phone:303-257-8237
Mailing Address - Fax:303-814-3761
Practice Address - Street 1:734 WILCOX ST
Practice Address - Street 2:#200
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-1709
Practice Address - Country:US
Practice Address - Phone:303-257-8237
Practice Address - Fax:303-814-3761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-10
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty