Provider Demographics
NPI:1689061079
Name:PALMER PARK DENTISTRY, LLC
Entity Type:Organization
Organization Name:PALMER PARK DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STERLING
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-597-3700
Mailing Address - Street 1:3208 N ACADEMY BLVD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5161
Mailing Address - Country:US
Mailing Address - Phone:719-597-3700
Mailing Address - Fax:719-597-7507
Practice Address - Street 1:3208 N ACADEMY BLVD
Practice Address - Street 2:SUITE 140
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-5161
Practice Address - Country:US
Practice Address - Phone:719-597-3700
Practice Address - Fax:719-597-7507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-23
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00007989122300000X
CO00201875122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO38873362Medicaid
CO97401862Medicaid