Provider Demographics
NPI:1558774521
Name:BRAD BURTWISTLE DDS, PC
Entity Type:Organization
Organization Name:BRAD BURTWISTLE DDS, PC
Other - Org Name:MONUMENT FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:BURTWISTLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, RN
Authorized Official - Phone:719-481-4949
Mailing Address - Street 1:PO BOX 492
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-0492
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-08
Last Update Date:2014-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2020451223G0001X
124Q00000X, 126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No126800000XDental ProvidersDental AssistantGroup - Multi-Specialty