Provider Demographics
NPI:1518580588
Name:PIASECKI, MICHELLE ELIZABETH
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ELIZABETH
Last Name:PIASECKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:ELIZABETH
Other - Last Name:COUGHLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3232 SAWTELLE BLVD APT 101
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-1616
Mailing Address - Country:US
Mailing Address - Phone:917-882-4205
Mailing Address - Fax:
Practice Address - Street 1:15854 JACKSON CREEK PKWY
Practice Address - Street 2:
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132-8662
Practice Address - Country:US
Practice Address - Phone:719-302-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-25
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002053261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice