Provider Demographics
NPI:1497132294
Name:WINTER MOUNTAIN, LLC
Entity Type:Organization
Organization Name:WINTER MOUNTAIN, LLC
Other - Org Name:RICKS FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:RICKS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:716-472-5745
Mailing Address - Street 1:21 KINGS CROSSING ROAD SUITE #206
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:CO
Mailing Address - Zip Code:80482
Mailing Address - Country:US
Mailing Address - Phone:716-472-5745
Mailing Address - Fax:
Practice Address - Street 1:21 KINGS CROSSING ROAD SUITE #206
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:CO
Practice Address - Zip Code:80482
Practice Address - Country:US
Practice Address - Phone:716-472-5745
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-30
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00202483261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental