Healthcare Provider Details

I. General information

NPI: 1386643955
Provider Name (Legal Business Name): KATHRYN ANN RADTKE D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 BRISTLECONE DR
FT COLLINS CO
80524-2031
US

IV. Provider business mailing address

2720 COUNCIL TREE AVE STE 260
FORT COLLINS CO
80525-6330
US

V. Phone/Fax

Practice location:
  • Phone: 970-416-5331
  • Fax: 970-472-0440
Mailing address:
  • Phone: 970-673-7321
  • Fax: 970-472-0440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8604
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: