Provider Demographics
NPI:1215234885
Name:FRIEDMAN, JESSE (DMD)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:FRIEDMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 CENTER GREEN DR
Mailing Address - Street 2:SUITE 215
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-2364
Mailing Address - Country:US
Mailing Address - Phone:303-442-6142
Mailing Address - Fax:303-443-6163
Practice Address - Street 1:3000 CENTER GREEN DR
Practice Address - Street 2:SUITE 215
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-2364
Practice Address - Country:US
Practice Address - Phone:303-442-6142
Practice Address - Fax:303-443-6163
Is Sole Proprietor?:No
Enumeration Date:2011-02-17
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CO106971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program