Provider Demographics
NPI:1275664542
Name:BROMELL, SUSAN C (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:C
Last Name:BROMELL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4254 W 107TH PL
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80031-7605
Mailing Address - Country:US
Mailing Address - Phone:303-456-1186
Mailing Address - Fax:
Practice Address - Street 1:9203 HURON ST
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80260-5495
Practice Address - Country:US
Practice Address - Phone:303-429-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO66361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02066363Medicaid