=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639031289
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIER DENTAL OF RIFLE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2025
-----------------------------------------------------
Last Update Date | 12/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 E 16TH ST
-----------------------------------------------------
City | RIFLE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81650-4711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-625-1850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 E 16TH ST
-----------------------------------------------------
City | RIFLE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81650-4711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | JESSE MCHALE
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 970-625-1850
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------