Provider Demographics
NPI:1720463664
Name:BORTOLINI, NATHAN MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:MICHAEL
Last Name:BORTOLINI
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 1:203 S ROLLIE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-1508
Mailing Address - Country:US
Mailing Address - Phone:303-286-4560
Mailing Address - Fax:303-286-4589
Practice Address - Street 1:1950 REDTAIL HAWK DR
Practice Address - Street 2:
Practice Address - City:ESTES PARK
Practice Address - State:CO
Practice Address - Zip Code:80517-9780
Practice Address - Country:US
Practice Address - Phone:033-697-2583
Practice Address - Fax:970-577-3464
Is Sole Proprietor?:No
Enumeration Date:2015-07-21
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00202588122300000X
CODEN.00202588122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO00882208Medicaid