Provider Demographics
NPI:1013359876
Name:BURTWISTLE, BRADLEY SCOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:SCOTT
Last Name:BURTWISTLE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 2ND ST STE A
Mailing Address - Street 2:PO BOX 492
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-7935
Mailing Address - Country:US
Mailing Address - Phone:719-481-4949
Mailing Address - Fax:719-481-4989
Practice Address - Street 1:325 2ND ST STE A
Practice Address - Street 2:
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132-7935
Practice Address - Country:US
Practice Address - Phone:719-481-4949
Practice Address - Fax:719-481-4989
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-22
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002020451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice