Provider Demographics
NPI:1184377392
Name:PAGOSA PEAK FAMILY DENTISTRY, PLLC
Entity type:Organization
Organization Name:PAGOSA PEAK FAMILY DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUKEMA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:216-374-5693
Mailing Address - Street 1:115 HAREBELL DR
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-7721
Mailing Address - Country:US
Mailing Address - Phone:216-374-5693
Mailing Address - Fax:
Practice Address - Street 1:228 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147-8308
Practice Address - Country:US
Practice Address - Phone:216-374-5693
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental