Provider Demographics
NPI:1972954949
Name:FRUITA CANYON DENTAL
Entity Type:Organization
Organization Name:FRUITA CANYON DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KREHL
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:STEGELMEIER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-858-8484
Mailing Address - Street 1:288 W PABOR AVE
Mailing Address - Street 2:
Mailing Address - City:FRUITA
Mailing Address - State:CO
Mailing Address - Zip Code:81521-2153
Mailing Address - Country:US
Mailing Address - Phone:970-858-8484
Mailing Address - Fax:970-858-6436
Practice Address - Street 1:288 W PABOR AVE
Practice Address - Street 2:
Practice Address - City:FRUITA
Practice Address - State:CO
Practice Address - Zip Code:81521-2153
Practice Address - Country:US
Practice Address - Phone:970-858-8484
Practice Address - Fax:970-858-8484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-30
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8989122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO16183274Medicaid