Provider Demographics
NPI:1992484844
Name:EXPERIENCE DENTAL HYGIENE PRACTICE 1 LLC
Entity type:Organization
Organization Name:EXPERIENCE DENTAL HYGIENE PRACTICE 1 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO EXTRORDINAIRE
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:ALTDORFER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:740-706-0765
Mailing Address - Street 1:3125 28TH ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1315
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3125 28TH ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1315
Practice Address - Country:US
Practice Address - Phone:720-996-0559
Practice Address - Fax:720-740-6760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental