Healthcare Provider Details

I. General information

NPI: 1972954949
Provider Name (Legal Business Name): FRUITA CANYON DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2016
Last Update Date: 06/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

288 W PABOR AVE
FRUITA CO
81521-2153
US

IV. Provider business mailing address

288 W PABOR AVE
FRUITA CO
81521-2153
US

V. Phone/Fax

Practice location:
  • Phone: 970-858-8484
  • Fax: 970-858-8484
Mailing address:
  • Phone: 970-858-8484
  • Fax: 970-858-6436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8989
License Number StateCO

VIII. Authorized Official

Name: KREHL WILLIAM STEGELMEIER
Title or Position: DENTIST
Credential: D.D.S.
Phone: 970-858-8484