Healthcare Provider Details

I. General information

NPI: 1285169623
Provider Name (Legal Business Name): TED C. KAWULOK, D.D.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2017
Last Update Date: 04/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 28TH ST SUITE 4
BOULDER CO
80303-1096
US

IV. Provider business mailing address

1400 28TH ST SUITE 4
BOULDER CO
80303-1096
US

V. Phone/Fax

Practice location:
  • Phone: 303-442-8625
  • Fax: 303-541-9867
Mailing address:
  • Phone: 303-442-8625
  • Fax: 303-541-9867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. TED C. KAWULOK
Title or Position: OWNER
Credential: D.D.S.
Phone: 303-442-8625