Healthcare Provider Details

I. General information

NPI: 1043286107
Provider Name (Legal Business Name): MICHAEL D JONES D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 PENROSE PL SUITE 107
BOULDER CO
80301-1809
US

IV. Provider business mailing address

4515 S MEADOW DR
BOULDER CO
80301-3950
US

V. Phone/Fax

Practice location:
  • Phone: 303-443-8250
  • Fax: 303-443-7397
Mailing address:
  • Phone: 303-530-7594
  • Fax: 303-530-7595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number6137
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: