Healthcare Provider Details

I. General information

NPI: 1376767475
Provider Name (Legal Business Name): SARAH SOHYUN BONG-THAKUR DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SARAH SOHYUN BONG DDS

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 01/06/2023
Certification Date: 01/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 W 120TH AVE STE 800
WESTMINSTER CO
80234-2747
US

IV. Provider business mailing address

1005 W 120TH AVE STE 800
WESTMINSTER CO
80234-2747
US

V. Phone/Fax

Practice location:
  • Phone: 720-263-5420
  • Fax:
Mailing address:
  • Phone: 720-263-5420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0401411892
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number00203802
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: