Provider Demographics
NPI:1215601257
Name:FAY, KATHLEEN E
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:E
Last Name:FAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1633 N PEARL ST APT 424
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80203-1644
Mailing Address - Country:US
Mailing Address - Phone:913-544-7876
Mailing Address - Fax:
Practice Address - Street 1:2780 S BROADWAY
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-1523
Practice Address - Country:US
Practice Address - Phone:303-783-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00204841122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist