Healthcare Provider Details

I. General information

NPI: 1285257279
Provider Name (Legal Business Name): JESSICA GONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2020
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4410 ARAPAHOE AVE STE 230
BOULDER CO
80303-1198
US

IV. Provider business mailing address

536 W 174TH AVE
BROOMFIELD CO
80023-5206
US

V. Phone/Fax

Practice location:
  • Phone: 303-442-4555
  • Fax:
Mailing address:
  • Phone: 770-596-6827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN.00204879
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
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:
Title or Position:
Credential:
Phone: