Provider Demographics
NPI:1760771695
Name:FORT COLLINS DENTAL GROUP, LLP
Entity Type:Organization
Organization Name:FORT COLLINS DENTAL GROUP, LLP
Other - Org Name:FORT COLLINS DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:F
Authorized Official - Last Name:RODGERS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-282-8877
Mailing Address - Street 1:2860 MICHELLE FL 2
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-1008
Mailing Address - Country:US
Mailing Address - Phone:714-368-2077
Mailing Address - Fax:714-368-2092
Practice Address - Street 1:2310 E HARMONY RD STE 103
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3427
Practice Address - Country:US
Practice Address - Phone:970-282-8877
Practice Address - Fax:970-226-1326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-31
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty