Provider Demographics
NPI:1356686182
Name:ROCKY MOUNTAIN DENTAL IMPLANT CENTER
Entity Type:Organization
Organization Name:ROCKY MOUNTAIN DENTAL IMPLANT CENTER
Other - Org Name:THE DENTAL IMPLANT CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/SOLE MBR
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-515-6700
Mailing Address - Street 1:1900 16TH ST
Mailing Address - Street 2:SUITE 1150
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80202-5120
Mailing Address - Country:US
Mailing Address - Phone:303-515-6700
Mailing Address - Fax:888-484-0355
Practice Address - Street 1:1900 16TH ST
Practice Address - Street 2:SUITE 1150
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80202-5120
Practice Address - Country:US
Practice Address - Phone:303-515-6700
Practice Address - Fax:888-484-0355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-05
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN 9555122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty