Healthcare Provider Details

I. General information

NPI: 1134341936
Provider Name (Legal Business Name): AMY LAURA PELOQUIN R.D.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 10/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 MAIN STREET UNIT A
ELIZABETH CO
80107
US

IV. Provider business mailing address

42048 S PINEHURST CIR
ELIZABETH CO
80107-9113
US

V. Phone/Fax

Practice location:
  • Phone: 303-653-2095
  • Fax:
Mailing address:
  • Phone: 303-653-2095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number904903
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: