Provider Demographics
NPI:1205212875
Name:HUETTNER, PETER CHARLES (DMD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:CHARLES
Last Name:HUETTNER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1091 E BAYAUD AVE APT W1502
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80209-2763
Mailing Address - Country:US
Mailing Address - Phone:507-358-5082
Mailing Address - Fax:
Practice Address - Street 1:4200 E 8TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220-3715
Practice Address - Country:US
Practice Address - Phone:507-358-5082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-06
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY058103122300000X
CODEN.002029011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist