Healthcare Provider Details

I. General information

NPI: 1720463664
Provider Name (Legal Business Name): NATHAN MICHAEL BORTOLINI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2015
Last Update Date: 04/07/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 REDTAIL HAWK DR
ESTES PARK CO
80517-9780
US

IV. Provider business mailing address

203 S ROLLIE AVE
FORT LUPTON CO
80621-1508
US

V. Phone/Fax

Practice location:
  • Phone: 33-697-2583
  • Fax: 970-577-3464
Mailing address:
  • Phone: 303-286-4560
  • Fax: 303-286-4589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number00202588
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN.00202588
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: