Healthcare Provider Details

I. General information

NPI: 1154848455
Provider Name (Legal Business Name): SCOTT WAYNE HIRSBRUNNER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2017
Last Update Date: 08/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3952 N ACADEMY BLVD
COLORADO SPRINGS CO
80917-5923
US

IV. Provider business mailing address

3952 N ACADEMY BLVD
COLORADO SPRINGS CO
80917-5923
US

V. Phone/Fax

Practice location:
  • Phone: 719-591-1811
  • Fax: 719-591-2032
Mailing address:
  • Phone: 719-591-1811
  • Fax: 719-591-2032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD009859
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number00203761
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: