Organization
INTEGRATED DERMATOLOGY OF BOULDER CREEK, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DAVID FUENTES (AUTHORIZED)
(561) 314-2000
Entity
Organization
Contact information
Practice address
400 S MCCASLIN BLVD STE 100, SUPERIOR, CO 80027-9701
(303) 666-5261
(303) 604-6062
Mailing address
4700 EXCHANGE CT STE 110, BOCA RATON, FL 33431-4450
(561) 431-2821
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
—
—
207ND0101X
MOHS-Micrographic Surgery Physician
—
—
363A00000X
Physician Assistant
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
9000168857
—
CO
Enumeration date
07/06/2021
Last updated
07/06/2021
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