Provider Demographics
NPI:1215362637
Name:ASTIASARAN, CODI ETEL (DDS)
Entity Type:Individual
Prefix:
First Name:CODI
Middle Name:ETEL
Last Name:ASTIASARAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 BIG BEND TRL
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79602-1272
Mailing Address - Country:US
Mailing Address - Phone:719-648-1468
Mailing Address - Fax:
Practice Address - Street 1:301 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CROSS PLAINS
Practice Address - State:TX
Practice Address - Zip Code:76443-2581
Practice Address - Country:US
Practice Address - Phone:254-725-4311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-04
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00202008122300000X
TX307201223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
No122300000XDental ProvidersDentist