Healthcare Provider Details

I. General information

NPI: 1033117239
Provider Name (Legal Business Name): GEORGE BRUCE DOUGLAS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 ARAPAHOE AVE SUITE #300
BOULDER CO
80303-1093
US

IV. Provider business mailing address

3100 ARAPAHOE AVE SUITE #300
BOULDER CO
80303-1093
US

V. Phone/Fax

Practice location:
  • Phone: 303-449-6621
  • Fax: 303-413-9341
Mailing address:
  • Phone: 303-449-6621
  • Fax: 303-413-9341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number104245
License Number StateCO

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: