Provider Demographics
NPI:1558757260
Name:FIRESTONE PEDIATRIC DENTISTRY AND ORTHODONTICS
Entity Type:Organization
Organization Name:FIRESTONE PEDIATRIC DENTISTRY AND ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:F
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:720-638-6114
Mailing Address - Street 1:8301 COLORADO BLVD, SUITE 200
Mailing Address - Street 2:
Mailing Address - City:FIRESTONE
Mailing Address - State:CO
Mailing Address - Zip Code:80504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8301 COLORADO BLVD, SUITE 200
Practice Address - Street 2:
Practice Address - City:FIRESTONE
Practice Address - State:CO
Practice Address - Zip Code:80504
Practice Address - Country:US
Practice Address - Phone:720-638-6114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1223P0221X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty