Provider Demographics
NPI:1962682567
Name:ROTOLO, GARY DANTE
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:DANTE
Last Name:ROTOLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1232 BERGEN PKWY
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-9573
Mailing Address - Country:US
Mailing Address - Phone:303-674-6070
Mailing Address - Fax:303-674-6071
Practice Address - Street 1:1232 BERGEN PKWY
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-9573
Practice Address - Country:US
Practice Address - Phone:303-674-6070
Practice Address - Fax:303-674-6071
Is Sole Proprietor?:No
Enumeration Date:2007-11-12
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO81211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO69708533Medicaid