Provider Demographics
NPI:1255396768
Name:ROLLERT, MICHAEL K (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:K
Last Name:ROLLERT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2750 E 136TH AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80241-3530
Mailing Address - Country:US
Mailing Address - Phone:720-452-2144
Mailing Address - Fax:303-379-9051
Practice Address - Street 1:2750 E 136TH AVE STE 101
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80241-3530
Practice Address - Country:US
Practice Address - Phone:720-452-2144
Practice Address - Fax:303-379-9051
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO76991223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
COB1865Medicare PIN
COU75866Medicare UPIN