Provider Demographics
NPI:1508086786
Name:FAKTOR, MICHAEL BRIAN (DMD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:BRIAN
Last Name:FAKTOR
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:PO BOX 1228
Mailing Address - Street 2:
Mailing Address - City:CRESTED BUTTE
Mailing Address - State:CO
Mailing Address - Zip Code:81224-1228
Mailing Address - Country:US
Mailing Address - Phone:970-319-9263
Mailing Address - Fax:970-349-9485
Practice Address - Street 1:412 ELK AVE.
Practice Address - Street 2:
Practice Address - City:CRESTED BUTTE
Practice Address - State:CO
Practice Address - Zip Code:81224-1228
Practice Address - Country:US
Practice Address - Phone:212-759-2955
Practice Address - Fax:970-349-9485
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-27
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8680122300000X
NY053098122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist