Provider Demographics
NPI:1861170110
Name:WITHYCOMBE, BRENDAN (DMD)
Entity type:Individual
Prefix:DR
First Name:BRENDAN
Middle Name:
Last Name:WITHYCOMBE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1612 MOUNT EVANS DR
Mailing Address - Street 2:
Mailing Address - City:LEADVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80461-3720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:360 PEAK ONE DR STE 325
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:CO
Practice Address - Zip Code:80443-5948
Practice Address - Country:US
Practice Address - Phone:970-668-4055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-07
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002057221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice