Provider Demographics
NPI:1255806212
Name:CHAMUT VILLARREAL, STEFFANY (DDS MPH)
Entity type:Individual
Prefix:DR
First Name:STEFFANY
Middle Name:
Last Name:CHAMUT VILLARREAL
Suffix:
Gender:F
Credentials:DDS MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 LONGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5819
Mailing Address - Country:US
Mailing Address - Phone:210-392-5157
Mailing Address - Fax:
Practice Address - Street 1:13065 E 17TH AVE RM 104L
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-2532
Practice Address - Country:US
Practice Address - Phone:210-392-5157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-05
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADF114451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1255806212Medicaid
MA0200140Medicaid