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General NPI Number Information
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NPI Number | 1922515204
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Entity Type | Organization
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Legal Business Name | BOULDER ROCK DENTAL, LLC
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Dates
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Enumeration Date | 01/08/2018
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Last Update Date | 06/12/2024
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Provider Practice Location Address
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Address Line | 5 BOULDER ROCK DR STE A
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City | PALM COAST
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State | FL
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Zip | 32137-8538
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Country | US
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Telephone | 386-931-1685
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Fax |
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Provider Business Mailing Address
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Address Line | 5 BOULDER ROCK DR STE A
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City | PALM COAST
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State | FL
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Zip | 32137-8538
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Country | US
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Telephone | 386-276-9051
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Fax | 386-276-9053
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | TANYA WHITAKER
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Credential |
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Telephone | 386-276-9051
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN15016
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License Number State | FL
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