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General NPI Number Information
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NPI Number | 1669846283
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Entity Type | Individual
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Provider Name | CORY FAUTEAUX
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Gender | Male
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Dates
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Enumeration Date | 11/19/2015
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Last Update Date | 11/19/2015
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Provider Practice Location Address
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Address Line | 111 SLIGO ST BLDG A
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City | CORTEZ
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State | CO
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Zip | 81321-2939
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Country | US
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Telephone | 970-459-1314
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Fax |
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Provider Business Mailing Address
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Address Line | 111 SLIGO ST BLDG A
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City | CORTEZ
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State | CO
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Zip | 81321-2939
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Country | US
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Telephone | 970-459-1314
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | DH.002024233
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License Number State | CO
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