Basic Information
| Provider Information | |||||||||
| NPI: | 1851466007 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROOT | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2785 HEATHROW DR | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809207233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192914749 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3630 AUSTIN BLUFFS PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809186663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193045400 | ||||||||
| FaxNumber: | 7193045409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2006 | ||||||||
| LastUpdateDate: | 11/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 7761 | CO | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1851466007 | 05 | CO | MEDICAID | DEN.00007761 | 01 | CO | CO DENTAL LICENSE | OTHER |