Provider Demographics
NPI:1972169654
Name:RASOULI DENTAL CARE LLC
Entity Type:Organization
Organization Name:RASOULI DENTAL CARE LLC
Other - Org Name:FAMILY DENTAL CLINIC LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JINA
Authorized Official - Middle Name:
Authorized Official - Last Name:RASOULI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-232-3095
Mailing Address - Street 1:1200 S WADSWORTH BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80232-5434
Mailing Address - Country:US
Mailing Address - Phone:303-733-7533
Mailing Address - Fax:303-733-9826
Practice Address - Street 1:1200 S WADSWORTH BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80232-5434
Practice Address - Country:US
Practice Address - Phone:303-733-7533
Practice Address - Fax:303-733-9826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-17
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1992997209Medicaid