Healthcare Provider Details

I. General information

NPI: 1578911780
Provider Name (Legal Business Name): MARY CHRISTA VIRGINIA LAMOTTE EFDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2016
Last Update Date: 05/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1631 WETZEL AVE BLDG 815
FORT CARSON CO
80913-4095
US

IV. Provider business mailing address

1631 WETZEL AVE BLDG 815
FORT CARSON CO
80913-4095
US

V. Phone/Fax

Practice location:
  • Phone: 719-526-5537
  • Fax: 719-524-2843
Mailing address:
  • Phone: 719-526-5537
  • Fax: 719-524-2843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: