Provider Demographics
NPI:1518744416
Name:ROCKY MOUNTAIN ORAL & MAXILLOFACIAL SURGERY, PROF LLC
Entity Type:Organization
Organization Name:ROCKY MOUNTAIN ORAL & MAXILLOFACIAL SURGERY, PROF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLLERT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-503-5039
Mailing Address - Street 1:2750 E 136TH AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80241-3530
Mailing Address - Country:US
Mailing Address - Phone:720-452-2144
Mailing Address - Fax:303-379-9051
Practice Address - Street 1:10375 PARK MEADOWS DR STE 150
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-6755
Practice Address - Country:US
Practice Address - Phone:720-452-2144
Practice Address - Fax:303-379-9051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty