Provider Demographics
NPI:1194170373
Name:ALTENBURG, JELLE (DDS)
Entity type:Individual
Prefix:
First Name:JELLE
Middle Name:
Last Name:ALTENBURG
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 1:100 WATCHTOWER DR
Mailing Address - Street 2:
Mailing Address - City:PATTERSON
Mailing Address - State:NY
Mailing Address - Zip Code:12563-2232
Mailing Address - Country:US
Mailing Address - Phone:845-306-1000
Mailing Address - Fax:
Practice Address - Street 1:100 WATCHTOWER DR
Practice Address - Street 2:
Practice Address - City:PATTERSON
Practice Address - State:NY
Practice Address - Zip Code:12563-2232
Practice Address - Country:US
Practice Address - Phone:845-306-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042454-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice