Provider Demographics
NPI:1790148369
Name:BRUSH FAMILY DENTISTRY PC
Entity Type:Organization
Organization Name:BRUSH FAMILY DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CAMERON
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:BIRCH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-842-2858
Mailing Address - Street 1:302 CAMERON ST
Mailing Address - Street 2:
Mailing Address - City:BRUSH
Mailing Address - State:CO
Mailing Address - Zip Code:80723-2017
Mailing Address - Country:US
Mailing Address - Phone:970-842-2858
Mailing Address - Fax:
Practice Address - Street 1:302 CAMERON ST
Practice Address - Street 2:
Practice Address - City:BRUSH
Practice Address - State:CO
Practice Address - Zip Code:80723-2017
Practice Address - Country:US
Practice Address - Phone:970-842-2858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10464122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty