Provider Demographics
NPI:1639599087
Name:TESFALDET, GOITOM
Entity Type:Individual
Prefix:
First Name:GOITOM
Middle Name:
Last Name:TESFALDET
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9073 E OXFORD DR
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80237-1922
Mailing Address - Country:US
Mailing Address - Phone:720-579-4871
Mailing Address - Fax:
Practice Address - Street 1:1245 E COLFAX AVE STE 301
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-2216
Practice Address - Country:US
Practice Address - Phone:303-832-8655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-24
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH.000905892124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist