Provider Demographics
NPI:1518561042
Name:TEQUILA SUNRISE BOULDER PLLC
Entity Type:Organization
Organization Name:TEQUILA SUNRISE BOULDER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAUSHAL
Authorized Official - Middle Name:KUMAR
Authorized Official - Last Name:DHAWAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:417-379-7923
Mailing Address - Street 1:4150 DARLEY AVE STE 7
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-6537
Mailing Address - Country:US
Mailing Address - Phone:303-494-1550
Mailing Address - Fax:
Practice Address - Street 1:4150 DARLEY AVE STE 7
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-6537
Practice Address - Country:US
Practice Address - Phone:303-494-1550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CODEN0202080OtherDENTAL LICENSE