Provider Demographics
NPI:1700042850
Name:BROCK WESTOVER, D.D.S., M-ED, PLLC
Entity Type:Organization
Organization Name:BROCK WESTOVER, D.D.S., M-ED, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:KJOLLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-420-2871
Mailing Address - Street 1:1440 28TH ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-1030
Mailing Address - Country:US
Mailing Address - Phone:303-443-2441
Mailing Address - Fax:
Practice Address - Street 1:1440 28TH ST
Practice Address - Street 2:SUITE 3
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1030
Practice Address - Country:US
Practice Address - Phone:303-443-2441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-29
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8571122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty