Provider Demographics
NPI:1255393765
Name:BRADY, KINGDON KIBBLE (DDS)
Entity type:Individual
Prefix:DR
First Name:KINGDON
Middle Name:KIBBLE
Last Name:BRADY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2627 REDWING RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-6321
Mailing Address - Country:US
Mailing Address - Phone:970-484-0250
Mailing Address - Fax:970-484-1522
Practice Address - Street 1:2627 REDWING RD
Practice Address - Street 2:SUITE 300
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-6321
Practice Address - Country:US
Practice Address - Phone:970-484-0250
Practice Address - Fax:970-484-1522
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010038A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200231810Medicaid