Healthcare Provider Details

I. General information

NPI: 1215894050
Provider Name (Legal Business Name): BOULDER DENTAL CENTER TABLE MESA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2026
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4790 TABLE MESA DR
BOULDER CO
80305-5600
US

IV. Provider business mailing address

4790 TABLE MESA DR
BOULDER CO
80305-5600
US

V. Phone/Fax

Practice location:
  • Phone: 303-442-5000
  • Fax:
Mailing address:
  • Phone: 303-442-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. DANNY ABBOUD
Title or Position: PRESIDENT
Credential: DDS
Phone: 303-442-5000