Provider Demographics
NPI:1023404399
Name:ROLF, SHANNON (RDH)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:ROLF
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 N UNION BLVD
Mailing Address - Street 2:STE101
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-2884
Mailing Address - Country:US
Mailing Address - Phone:719-633-2266
Mailing Address - Fax:
Practice Address - Street 1:1512 N UNION BLVD
Practice Address - Street 2:STE101
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-2884
Practice Address - Country:US
Practice Address - Phone:719-633-2266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-13
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO000904276124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist