Provider Demographics
NPI:1568752426
Name:MICHAEL K. ROLLERT, DDS, LLC
Entity Type:Organization
Organization Name:MICHAEL K. ROLLERT, DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:ROLLERT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-503-5039
Mailing Address - Street 1:2372 S HUMBOLDT ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-5113
Mailing Address - Country:US
Mailing Address - Phone:303-503-5039
Mailing Address - Fax:
Practice Address - Street 1:2372 S HUMBOLDT ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210-5113
Practice Address - Country:US
Practice Address - Phone:303-503-5039
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-13
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO76991223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CB1865OtherMEDICARE PTAN
CB1865OtherMEDICARE PTAN