Provider Demographics
NPI:1255706115
Name:ALPINE WEST FORT COLLINS LLC
Entity type:Organization
Organization Name:ALPINE WEST FORT COLLINS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMEBER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-484-5297
Mailing Address - Street 1:718 S COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-3301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1015 S TAFT HILL RD
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80521-4240
Practice Address - Country:US
Practice Address - Phone:970-482-6034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALPINE DENTAL HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-12-03
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO83191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty