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General NPI Number Information
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NPI Number | 1306347182
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Entity Type | Organization
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Legal Business Name | BRIDGE STREET DENTAL, PLLC
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Dates
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Enumeration Date | 02/26/2018
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Last Update Date | 02/26/2018
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Provider Practice Location Address
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Address Line | 19 N 42ND AVE
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City | BRIGHTON
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State | CO
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Zip | 80601-4351
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Country | US
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Telephone | 720-583-1425
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Fax |
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Provider Business Mailing Address
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Address Line | 19 N 42ND AVE
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City | BRIGHTON
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State | CO
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Zip | 80601-4351
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. TRAVIS WHITELEY
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Credential | DMD
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Telephone | 801-376-9484
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 8920
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License Number State | CO
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