Provider Demographics
NPI:1568520955
Name:WORTHAM, ROY
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:
Last Name:WORTHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 NICKEL ST
Mailing Address - Street 2:SUITE 11
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-2013
Mailing Address - Country:US
Mailing Address - Phone:303-635-1816
Mailing Address - Fax:
Practice Address - Street 1:300 NICKEL ST
Practice Address - Street 2:SUITE 11
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-2013
Practice Address - Country:US
Practice Address - Phone:303-635-1816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN67101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice