Organization
PEDIATRIC DENTISTRY OF THE ROCKIES PLLC
Active
Other names
Pediatric Dentistry of the Rockies
Organization subpart
No
Provider details
NPI number
Authorized official
KEITH ALLEN VAN TASSELL (PRESIDENT/OWNER)
(970) 484-4104
Entity
Organization
Contact information
Practice address
4609 S TIMBERLINE RD, SUITE 103B, FORT COLLINS, CO 80528-3170
(970) 484-4104
(970) 484-5245
Mailing address
4609 S TIMBERLINE RD, SUITE 103B, FORT COLLINS, CO 80528-3170
(970) 484-4104
(970) 484-5245
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
9197
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
82906505
—
CO
Enumeration date
02/14/2008
Last updated
10/23/2018
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