Provider Demographics
NPI:1871585729
Name:THOMASON, ETHELYN GAIL (DMD)
Entity type:Individual
Prefix:DR
First Name:ETHELYN
Middle Name:GAIL
Last Name:THOMASON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4155 DARLEY AVE
Mailing Address - Street 2:STE F
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-6536
Mailing Address - Country:US
Mailing Address - Phone:303-499-9700
Mailing Address - Fax:303-499-2528
Practice Address - Street 1:4155 DARLEY AVE
Practice Address - Street 2:STE F
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-6536
Practice Address - Country:US
Practice Address - Phone:303-499-9700
Practice Address - Fax:303-499-2528
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO83991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice