Provider Demographics
NPI:1336316579
Name:DERLOSHON, PEGGY ANN (DDS)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:ANN
Last Name:DERLOSHON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 BRISTLECONE DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-2031
Mailing Address - Country:US
Mailing Address - Phone:970-224-5209
Mailing Address - Fax:970-221-7165
Practice Address - Street 1:120 BRISTLECONE DR
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-2031
Practice Address - Country:US
Practice Address - Phone:970-224-5209
Practice Address - Fax:970-221-7165
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO66291223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health