Provider Demographics
NPI:1366747016
Name:CRANIOFACIAL PAIN CLINIC PC
Entity type:Organization
Organization Name:CRANIOFACIAL PAIN CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-758-2980
Mailing Address - Street 1:3540 S POPLAR ST
Mailing Address - Street 2:STE 301
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80237-1360
Mailing Address - Country:US
Mailing Address - Phone:303-758-4865
Mailing Address - Fax:303-756-8551
Practice Address - Street 1:3540 S POPLAR ST
Practice Address - Street 2:STE 301
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80237-1360
Practice Address - Country:US
Practice Address - Phone:303-758-4865
Practice Address - Fax:303-756-8551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-11
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO104945122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO6475020001Medicare PIN