Healthcare Provider Details

I. General information

NPI: 1578284550
Provider Name (Legal Business Name): CHILDREN'S DENTISTRY, BOULDER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2022
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 PENROSE PL STE 107
BOULDER CO
80301-1809
US

IV. Provider business mailing address

3400 PENROSE PL STE 107
BOULDER CO
80301-1809
US

V. Phone/Fax

Practice location:
  • Phone: 303-443-8250
  • Fax:
Mailing address:
  • Phone: 303-443-8250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier8954
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name: DR. SEAN WHALEN
Title or Position: OWNER/PEDIATRIC DENTIST
Credential: DDS
Phone: 720-226-6061