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? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223E0200X | Dental Providers | Dentist | Endodontics | Group - Multi-Specialty |