Healthcare Provider Details

I. General information

NPI: 1740310788
Provider Name (Legal Business Name): BOULDER ENDODONTICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 02/14/2008
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 Number
License Number StateCO

VII. Legacy identifiers

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

# 1
Identifier1033117239
Identifier TypeOTHER
Identifier StateCO
Identifier IssuerG. BRUCE DOUGLAS, D.D.S.
# 2
Identifier1740310788
Identifier TypeOTHER
Identifier StateCO
Identifier IssuerBOULDER ENDODONTICS, PC
# 3
Identifier1487652582
Identifier TypeOTHER
Identifier StateCO
Identifier IssuerJOSEPH R. PARSONS, D.D.S.

VIII. Authorized Official

Name: DR. GEORGE BRUCE DOUGLAS
Title or Position: ENDODONTIST
Credential: D.D.S.
Phone: 303-449-6621