Provider Demographics
NPI:1104246875
Name:ICHIYASU, PAMELA D (R D H)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:D
Last Name:ICHIYASU
Suffix:
Gender:F
Credentials:R D H
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 BEACON HILL DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80126-4268
Mailing Address - Country:US
Mailing Address - Phone:303-378-4977
Mailing Address - Fax:
Practice Address - Street 1:5031 S ULSTER ST
Practice Address - Street 2:SUITE 100
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80237-2804
Practice Address - Country:US
Practice Address - Phone:303-779-8587
Practice Address - Fax:303-779-9182
Is Sole Proprietor?:No
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO906146124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist