Provider Demographics
NPI:1356621122
Name:EVERGREEN DENTAL PARTNERS LLP
Entity type:Organization
Organization Name:EVERGREEN DENTAL PARTNERS LLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:ROTOLO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-674-6070
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8121122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO69708533Medicaid