Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223D0004X | Dentist Anesthesiologist | DEN.00008879 | CO |
N | 1223P0221X | Pediatric Dentist | 8879 | CO |
NPI | 1043325319 |
---|---|
Provider Name | Brett Wallen |
First Address | Aurora, CO 80045-7106 |
Second Address | Aurora, CO 80045-7106 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/08/2006 |
Last Update Date | 30/11/2018 |