Provider Demographics
NPI:1073669073
Name:HUSTAFA, MARIE L (RDH)
Entity Type:Individual
Prefix:MS
First Name:MARIE
Middle Name:L
Last Name:HUSTAFA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 140
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81302-0140
Mailing Address - Country:US
Mailing Address - Phone:970-247-5702
Mailing Address - Fax:970-247-9126
Practice Address - Street 1:281 SAWYER DR
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81303-3409
Practice Address - Country:US
Practice Address - Phone:970-247-5702
Practice Address - Fax:970-247-9126
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO904555124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO80528201Medicaid