Provider Demographics
NPI:1770833113
Name:ADVANCED DENTAL, INC.
Entity Type:Organization
Organization Name:ADVANCED DENTAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:ROCKNAK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-685-1371
Mailing Address - Street 1:7112 COMMONS CIR
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-9999
Mailing Address - Country:US
Mailing Address - Phone:970-685-1371
Mailing Address - Fax:
Practice Address - Street 1:7112 COMMONS CIR
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-9999
Practice Address - Country:US
Practice Address - Phone:970-685-1371
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY13021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty