Provider Demographics
NPI:1255333720
Name:RENEHAN, BRADLEY WILLIAM (MDDDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:WILLIAM
Last Name:RENEHAN
Suffix:
Gender:M
Credentials:MDDDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 SOUTHPOINTE CT
Mailing Address - Street 2:#150
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-3856
Mailing Address - Country:US
Mailing Address - Phone:719-540-6350
Mailing Address - Fax:719-527-9487
Practice Address - Street 1:640 SOUTHPOINTE CT
Practice Address - Street 2:#150
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3856
Practice Address - Country:US
Practice Address - Phone:719-540-6350
Practice Address - Fax:719-527-9487
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO85081223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO29054842Medicaid
CO29054842Medicaid