Provider Demographics
NPI:1215960976
Name:FLATROCK FAMILY DENTISTRY, P.C.
Entity type:Organization
Organization Name:FLATROCK FAMILY DENTISTRY, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:WALROD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:308-534-8080
Mailing Address - Street 1:1225 S POPLAR ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-7785
Mailing Address - Country:US
Mailing Address - Phone:308-534-8080
Mailing Address - Fax:
Practice Address - Street 1:1225 S POPLAR ST
Practice Address - Street 2:SUITE 500
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-7785
Practice Address - Country:US
Practice Address - Phone:308-534-8080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE60521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========00Medicaid