Provider Demographics
NPI:1063534642
Name:ROCKY MOUNTAIN ORAL & MAXILLOFACIAL SURGERY
Entity type:Organization
Organization Name:ROCKY MOUNTAIN ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:ROLLERT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-798-2208
Mailing Address - Street 1:7889 S LINCOLN CT
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80122-2651
Mailing Address - Country:US
Mailing Address - Phone:303-798-4553
Mailing Address - Fax:303-798-2208
Practice Address - Street 1:7889 S LINCOLN CT
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80122-2651
Practice Address - Country:US
Practice Address - Phone:303-798-4553
Practice Address - Fax:303-798-2208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO76991223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCB1805Medicare PIN
COB1805Medicare ID - Type Unspecified