Provider Demographics
NPI:1104494632
Name:KASTELIC, PARKER THEODORE I (DMD)
Entity type:Individual
Prefix:
First Name:PARKER
Middle Name:THEODORE
Last Name:KASTELIC
Suffix:I
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 N COMMERCIAL ST APT 201
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CO
Mailing Address - Zip Code:81082-1903
Mailing Address - Country:US
Mailing Address - Phone:920-838-2258
Mailing Address - Fax:
Practice Address - Street 1:2124 FREEDOM RD
Practice Address - Street 2:
Practice Address - City:TRINIDAD
Practice Address - State:CO
Practice Address - Zip Code:81082-1210
Practice Address - Country:US
Practice Address - Phone:719-422-5696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00204748122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist