MEDICARE: DR. PAMELA SUSANNE MILOS VALSTAD DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	7737	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7737	OTHER	CO	DENTAL LICENSE NUMBER

General Provider Information

NPI Number	:	1689675407
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PAMELA SUSANNE MILOS VALSTAD DMD

Provider Business Mailing Address
First Line	:	1350 BASSETERRE PLACE
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525
Country	:	US
Telephone Number	:	970-207-4024
Fax Number	:	970-207-4024

Provider Business Practice Location Address
First Line	:	519 MAIN STREET
Second Line	:
City	:	WINDSOR
State	:	CO
Zip	:	80550
Country	:	US
Telephone Number	:	970-686-7121
Fax Number	:	970-686-1021

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	07/08/2007

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