Provider Demographics
NPI:1083455067
Name:LOUSTALET, COLLIN
Entity type:Individual
Prefix:
First Name:COLLIN
Middle Name:
Last Name:LOUSTALET
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17480 E CLOUDBERRY DR
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-8848
Mailing Address - Country:US
Mailing Address - Phone:303-345-1660
Mailing Address - Fax:
Practice Address - Street 1:15250 E ORCHARD RD
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80016-3003
Practice Address - Country:US
Practice Address - Phone:303-680-9990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-04
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002059671223G0001X
NE182122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice