Provider Demographics
NPI:1972287217
Name:SOUTH BOULDER PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:SOUTH BOULDER PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PEDIATRIC DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAFFEO GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:720-441-2974
Mailing Address - Street 1:2945 MOORHEAD AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-3342
Mailing Address - Country:US
Mailing Address - Phone:720-441-2974
Mailing Address - Fax:
Practice Address - Street 1:805 S BROADWAY ST STE 103
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-5972
Practice Address - Country:US
Practice Address - Phone:720-441-2974
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty