Provider Demographics
NPI:1952708877
Name:EDWARD J. BERTAGNOLLI, DDS, PC
Entity Type:Organization
Organization Name:EDWARD J. BERTAGNOLLI, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:O
Authorized Official - Last Name:BERTAGNOLLI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-429-6222
Mailing Address - Street 1:7280 BRADBURN BLVD.
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80030
Mailing Address - Country:US
Mailing Address - Phone:303-429-6222
Mailing Address - Fax:303-429-7247
Practice Address - Street 1:7280 BRADBURN BLVD.
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80030
Practice Address - Country:US
Practice Address - Phone:303-429-6222
Practice Address - Fax:303-429-7247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-20
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COHDL00161122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO51424215Medicaid