Provider Demographics
NPI:1104130293
Name:BOULDER MODERN DENTISTRY, LLP
Entity type:Organization
Organization Name:BOULDER MODERN DENTISTRY, LLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTRACTS ADMIN
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCGLASHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-442-4455
Mailing Address - Street 1:2860 MICHELLE FL 2
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-1008
Mailing Address - Country:US
Mailing Address - Phone:714-368-2077
Mailing Address - Fax:714-368-2092
Practice Address - Street 1:2100 28TH ST STE 4F
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1106
Practice Address - Country:US
Practice Address - Phone:303-442-4455
Practice Address - Fax:303-443-0972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-30
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty