Healthcare Provider Details

I. General information

NPI: 1558757260
Provider Name (Legal Business Name): FIRESTONE PEDIATRIC DENTISTRY AND ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2015
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7613 ESTHER CIR
FREDERICK CO
80504-5881
US

IV. Provider business mailing address

8301 COLORADO BLVD, SUITE 200
FIRESTONE CO
80504
US

V. Phone/Fax

Practice location:
  • Phone: 720-638-6114
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number StateCO

VIII. Authorized Official

Name: DR. MATTHEW F BRADY
Title or Position: OWNER
Credential: DDS
Phone: 757-462-6602