Provider Demographics
NPI:1861588683
Name:KNOWLTON, ANTHONY L (DDS)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:L
Last Name:KNOWLTON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 S UNION AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3429
Mailing Address - Country:US
Mailing Address - Phone:719-564-5833
Mailing Address - Fax:719-564-7097
Practice Address - Street 1:317 S UNION AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-3429
Practice Address - Country:US
Practice Address - Phone:719-564-5833
Practice Address - Fax:719-564-7097
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO9242122300000X
CO92421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO72903554Medicaid