Provider Demographics
NPI:1538786421
Name:FUGLAAR, COLETTE LAREE (DMD)
Entity type:Individual
Prefix:DR
First Name:COLETTE
Middle Name:LAREE
Last Name:FUGLAAR
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:COLETTE
Other - Middle Name:LAREE
Other - Last Name:CHILDRESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9895 S MARYLAND PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89183-7165
Mailing Address - Country:US
Mailing Address - Phone:702-372-4039
Mailing Address - Fax:
Practice Address - Street 1:9895 S MARYLAND PKWY STE A
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89183-7165
Practice Address - Country:US
Practice Address - Phone:702-372-4039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-26
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV73811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice