Healthcare Provider Details

I. General information

NPI: 1548864358
Provider Name (Legal Business Name): BOULDER VALLEY DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2020
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 N MAIN ST
BOULDER MT
59632-7761
US

IV. Provider business mailing address

PO BOX 512
BOULDER MT
59632-0512
US

V. Phone/Fax

Practice location:
  • Phone: 406-225-4222
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: LISA HUEMPFNER
Title or Position: OWNER/DENTIST
Credential: DMD
Phone: 262-497-5559