Healthcare Provider Details

I. General information

NPI: 1215110630
Provider Name (Legal Business Name): DINA BRUDENELL, MD, PROFESSIONAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

4745 ARAPAHOE AVE STE 310
BOULDER CO
80303-1082
US

IV. Provider business mailing address

4745 ARAPAHOE AVE STE 310
BOULDER CO
80303-1082
US

V. Phone/Fax

Practice location:
  • Phone: 303-442-2913
  • Fax: 303-444-6198
Mailing address:
  • Phone: 303-442-2913
  • Fax: 303-444-6198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20118
License Number StateCO

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DINA BRUDENELL
Title or Position: OWNER
Credential:
Phone: 303-442-2913