Provider Demographics
NPI:1790190254
Name:HAMILTON, SUNNI
Entity Type:Individual
Prefix:
First Name:SUNNI
Middle Name:
Last Name:HAMILTON
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 1:510 ELK AVENUE
Mailing Address - Street 2:
Mailing Address - City:CRESTED BUTTE
Mailing Address - State:CO
Mailing Address - Zip Code:81224
Mailing Address - Country:US
Mailing Address - Phone:970-349-5577
Mailing Address - Fax:970-349-5578
Practice Address - Street 1:510 ELK AVENUE
Practice Address - Street 2:SUITE 2
Practice Address - City:CRESTED BUTTE
Practice Address - State:CO
Practice Address - Zip Code:81224
Practice Address - Country:US
Practice Address - Phone:970-349-5577
Practice Address - Fax:970-349-5578
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-24
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002023818124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO170694504Medicaid