Provider Demographics
NPI:1851877674
Name:SELKOW, AMBER M
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:M
Last Name:SELKOW
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 1:915 N PINE ST
Mailing Address - Street 2:
Mailing Address - City:GUNNISON
Mailing Address - State:CO
Mailing Address - Zip Code:81230-2643
Mailing Address - Country:US
Mailing Address - Phone:970-569-8569
Mailing Address - Fax:
Practice Address - Street 1:100 E GOTHIC AVE
Practice Address - Street 2:
Practice Address - City:GUNNISON
Practice Address - State:CO
Practice Address - Zip Code:81230-2216
Practice Address - Country:US
Practice Address - Phone:970-596-8569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-15
Last Update Date:2018-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO000906047124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist