Healthcare Provider Details

I. General information

NPI: 1063084481
Provider Name (Legal Business Name): BOULDER ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 1ST ST
FIRESTONE CO
80520-5006
US

IV. Provider business mailing address

2710 PEARL ST
BOULDER CO
80302-3814
US

V. Phone/Fax

Practice location:
  • Phone: 303-833-0310
  • Fax:
Mailing address:
  • Phone: 303-449-3250
  • Fax: 303-449-1693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMON VERL JENSEN
Title or Position: OWNER
Credential:
Phone: 303-833-0310