Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 904555 | CO |
NPI | 1073669073 |
---|---|
Provider Name | Ms. Marie L Hustafa |
First Address | Durango, CO 81302-0140 |
Second Address | Durango, CO 81303-3409 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/01/2007 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
80528201 | (05) | CO |