Provider Demographics
NPI:1467967307
Name:BOULDER ORAL SURGERY
Entity Type:Organization
Organization Name:BOULDER ORAL SURGERY
Other - Org Name:BOULDER ORAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRENCE
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:NEDBALSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-447-9735
Mailing Address - Street 1:3450 PENROSE PL
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1800
Mailing Address - Country:US
Mailing Address - Phone:303-447-9735
Mailing Address - Fax:303-447-1025
Practice Address - Street 1:3450 PENROSE PL STE 120
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1800
Practice Address - Country:US
Practice Address - Phone:303-447-9735
Practice Address - Fax:303-447-9735
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TERRENCE NEDBALSKI DDS PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-12-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO94101223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty