Provider Demographics
NPI:1710410543
Name:BUFFALO PARK DENTISTRY
Entity Type:Organization
Organization Name:BUFFALO PARK DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:R
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:785-766-4991
Mailing Address - Street 1:28577 BUFFALO PARK RD
Mailing Address - Street 2:STE 260
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-7370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28577 BUFFALO PARK RD
Practice Address - Street 2:STE260
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-7370
Practice Address - Country:US
Practice Address - Phone:785-766-4991
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-08
Last Update Date:2017-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO103001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty