Healthcare Provider Details

I. General information

NPI: 1750505814
Provider Name (Legal Business Name): NICHOLAS MICHAEL POULOS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 N BROADWAY STE 1135
DENVER CO
80203-3444
US

IV. Provider business mailing address

700 N BROADWAY STE 1135
DENVER CO
80203-3444
US

V. Phone/Fax

Practice location:
  • Phone: 303-832-4867
  • Fax:
Mailing address:
  • Phone: 303-832-4867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN013389
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number9795
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: