Provider Demographics
NPI:1821252230
Name:WHEAT RIDGE FAMILY DENTAL
Entity Type:Organization
Organization Name:WHEAT RIDGE FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LEOPOLDO
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-940-9755
Mailing Address - Street 1:7015 W 38TH AVE
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-4876
Mailing Address - Country:US
Mailing Address - Phone:303-940-9755
Mailing Address - Fax:303-940-0811
Practice Address - Street 1:7015 W 38TH AVE
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-4876
Practice Address - Country:US
Practice Address - Phone:303-940-9755
Practice Address - Fax:303-940-0811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-15
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2481302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO32779755Medicaid