Provider Demographics
NPI:1043612062
Name:WS BOULDER RD DENTAL PC
Entity Type:Organization
Organization Name:WS BOULDER RD DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:720-625-1968
Mailing Address - Street 1:625 HOLLY DR
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:CO
Mailing Address - Zip Code:80751-4539
Mailing Address - Country:US
Mailing Address - Phone:970-522-5454
Mailing Address - Fax:970-522-5454
Practice Address - Street 1:625 HOLLY DR
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:CO
Practice Address - Zip Code:80751-4539
Practice Address - Country:US
Practice Address - Phone:970-522-5454
Practice Address - Fax:970-522-5454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-22
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7990122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO67402577Medicaid
CO463691741OtherPROFESSIONAL DENTAL GROUP