Healthcare Provider Details

I. General information

NPI: 1508086786
Provider Name (Legal Business Name): MICHAEL BRIAN FAKTOR DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2007
Last Update Date: 02/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 ELK AVE.
CRESTED BUTTE CO
81224-1228
US

IV. Provider business mailing address

PO BOX 1228
CRESTED BUTTE CO
81224-1228
US

V. Phone/Fax

Practice location:
  • Phone: 212-759-2955
  • Fax: 970-349-9485
Mailing address:
  • Phone: 970-319-9263
  • Fax: 970-349-9485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8680
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number053098
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: