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General NPI Number Information
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NPI Number | 1023589181
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Entity Type | Organization
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Legal Business Name | BASALT DENTISTRY, PC
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Dates
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Enumeration Date | 12/16/2018
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Last Update Date | 04/29/2019
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Provider Practice Location Address
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Address Line | 227 MIDLAND AVE STE C3
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City | BASALT
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State | CO
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Zip | 81621-8119
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Country | US
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Telephone | 970-927-5437
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Fax |
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Provider Business Mailing Address
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Address Line | 227 MIDLAND AVE STE C3
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City | BASALT
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State | CO
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Zip | 81621-8119
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Country | US
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Telephone | 970-927-5437
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Fax |
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | DR. JONATHAN JAMES HAERTER
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Credential | DDS
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Telephone | 970-376-4769
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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