Provider Demographics
NPI:1417940727
Name:VESTAL, JOHN ALTON III (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ALTON
Last Name:VESTAL
Suffix:III
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 W MONTEZUMA AVE
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-2750
Mailing Address - Country:US
Mailing Address - Phone:970-565-3612
Mailing Address - Fax:970-565-6069
Practice Address - Street 1:302 W MONTEZUMA AVE
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-2750
Practice Address - Country:US
Practice Address - Phone:970-565-3612
Practice Address - Fax:970-565-6069
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7935332B00000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies