Healthcare Provider Details

I. General information

NPI: 1558774521
Provider Name (Legal Business Name): BRAD BURTWISTLE DDS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2014
Last Update Date: 06/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 2ND ST STE A
MONUMENT CO
80132-7935
US

IV. Provider business mailing address

PO BOX 492
MONUMENT CO
80132-0492
US

V. Phone/Fax

Practice location:
  • Phone: 719-481-4949
  • Fax: 719-481-4989
Mailing address:
  • Phone: 719-481-4949
  • Fax: 719-481-4989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number202045
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name: DR. BRAD BURTWISTLE
Title or Position: PRESIDENT
Credential: DDS, RN
Phone: 719-481-4949