Healthcare Provider Details

I. General information

NPI: 1245384643
Provider Name (Legal Business Name): DAVID C FUNDERBURK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 W 16TH ST SUITE H
GREELEY CO
80634-6862
US

IV. Provider business mailing address

3400 W 16TH ST SUITE H
GREELEY CO
80634-6862
US

V. Phone/Fax

Practice location:
  • Phone: 970-356-8650
  • Fax:
Mailing address:
  • Phone: 970-356-8650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number105372
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: