Provider Demographics
NPI:1932316841
Name:JERRY THALKEN, DDS
Entity Type:Organization
Organization Name:JERRY THALKEN, DDS
Other - Org Name:RAY E LACK, DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BORER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-721-1735
Mailing Address - Street 1:5130 W 80TH AVE
Mailing Address - Street 2:BLDG A STE 200
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80030-4450
Mailing Address - Country:US
Mailing Address - Phone:303-429-1426
Mailing Address - Fax:
Practice Address - Street 1:5130 W 80TH AVE
Practice Address - Street 2:BLDG A STE 200
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80030-4450
Practice Address - Country:US
Practice Address - Phone:303-429-1426
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO89821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty