Provider Demographics
NPI:1245454081
Name:SHORT, JOHN A (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:SHORT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 245
Mailing Address - Street 2:
Mailing Address - City:NIWOT
Mailing Address - State:CO
Mailing Address - Zip Code:80544-0245
Mailing Address - Country:US
Mailing Address - Phone:303-443-0070
Mailing Address - Fax:303-430-0073
Practice Address - Street 1:2525 28TH ST UNIT 140
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1255
Practice Address - Country:US
Practice Address - Phone:303-443-0070
Practice Address - Fax:303-443-0073
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO100929122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist