MEDICARE: MINDFUL DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1952069205
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDFUL DENTISTRY

Provider Business Mailing Address
First Line	:	1609 ZINNIA CIR
Second Line	:
City	:	LAFAYETTE
State	:	CO
Zip	:	80026-9371
Country	:	US
Telephone Number	:	410-428-1201
Fax Number	:

Provider Business Practice Location Address
First Line	:	3100 ARAPAHOE AVE STE 100
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80303-1050
Country	:	US
Telephone Number	:	303-499-0367
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. ALESIA BERGAN
Credential	:	DDS
Telephone Number	:	410-428-1201

Provider Enumeration Date	:	12/03/2021
Last Update Date	:	12/03/2021

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