Provider Demographics
NPI:1982861829
Name:COLLEEN QUESADA DMD PLLC
Entity Type:Organization
Organization Name:COLLEEN QUESADA DMD PLLC
Other - Org Name:FARWELL FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:QUESADA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:989-588-4121
Mailing Address - Street 1:301 W MAIN ST
Mailing Address - Street 2:PO BOX 309
Mailing Address - City:FARWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48622-8753
Mailing Address - Country:US
Mailing Address - Phone:989-588-4121
Mailing Address - Fax:989-588-3191
Practice Address - Street 1:301 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FARWELL
Practice Address - State:MI
Practice Address - Zip Code:48622-8753
Practice Address - Country:US
Practice Address - Phone:989-588-4121
Practice Address - Fax:989-588-3191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI18173122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID801268OtherBCBS OF MI PIN