Provider Demographics
NPI:1154848455
Name:HIRSBRUNNER, SCOTT WAYNE (DMD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:WAYNE
Last Name:HIRSBRUNNER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3952 N ACADEMY BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5923
Mailing Address - Country:US
Mailing Address - Phone:719-591-1811
Mailing Address - Fax:719-591-2032
Practice Address - Street 1:3952 N ACADEMY BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-5923
Practice Address - Country:US
Practice Address - Phone:719-591-1811
Practice Address - Fax:719-591-2032
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-28
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0098591223G0001X
CO00203761122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000173303Medicaid