Provider Demographics
NPI:1023393030
Name:MUSTIAN, ANDREA M (DMD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:M
Last Name:MUSTIAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 HAWK RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026
Mailing Address - Country:US
Mailing Address - Phone:720-256-9049
Mailing Address - Fax:
Practice Address - Street 1:2006 BROADWAY ST
Practice Address - Street 2:#201
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-5255
Practice Address - Country:US
Practice Address - Phone:303-443-4984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-21
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO105711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice