Provider Demographics
NPI:1154434082
Name:DISTELHORST, DOROTHY ELLEN (DDS)
Entity type:Individual
Prefix:DR
First Name:DOROTHY
Middle Name:ELLEN
Last Name:DISTELHORST
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:PO BOX 5680
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CO
Mailing Address - Zip Code:81620-5680
Mailing Address - Country:US
Mailing Address - Phone:970-479-0408
Mailing Address - Fax:970-479-7903
Practice Address - Street 1:51 EAGLE RD # A1
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CO
Practice Address - Zip Code:81620-5991
Practice Address - Country:US
Practice Address - Phone:970-479-0408
Practice Address - Fax:970-479-7903
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO65331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice