Provider Demographics
NPI:1508146630
Name:CASTLE ROCK ORAL AND MAXILLOFACIAL SURGERY, PC
Entity Type:Organization
Organization Name:CASTLE ROCK ORAL AND MAXILLOFACIAL SURGERY, PC
Other - Org Name:CASTLE ROCK ORAL AND FACIAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTOPHER
Authorized Official - Middle Name:LARKIN
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:254-449-6581
Mailing Address - Street 1:2352 MEADOWS BLVD
Mailing Address - Street 2:205
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80109-8406
Mailing Address - Country:US
Mailing Address - Phone:303-663-7890
Mailing Address - Fax:888-765-9130
Practice Address - Street 1:2352 MEADOWS BLVD
Practice Address - Street 2:205
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80109-8406
Practice Address - Country:US
Practice Address - Phone:303-663-7890
Practice Address - Fax:888-765-9130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-20
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO102141223S0112X, 204E00000X
TX215121223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty