Provider Demographics
NPI:1548864358
Name:BOULDER VALLEY DENTAL LLC
Entity type:Organization
Organization Name:BOULDER VALLEY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:HUEMPFNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:262-497-5559
Mailing Address - Street 1:PO BOX 512
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:MT
Mailing Address - Zip Code:59632-0512
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:211 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:MT
Practice Address - Zip Code:59632-7761
Practice Address - Country:US
Practice Address - Phone:406-225-4222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty