Provider Demographics
NPI:1740536820
Name:POULSON, JEFFERY K (DDS)
Entity type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:K
Last Name:POULSON
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 1:5678 S JERICHO WAY
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80015-3652
Mailing Address - Country:US
Mailing Address - Phone:303-627-6244
Mailing Address - Fax:
Practice Address - Street 1:16900 E QUINCY AVE
Practice Address - Street 2:UNIT B
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80015-3299
Practice Address - Country:US
Practice Address - Phone:303-617-4488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-26
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO201810122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist