Provider Demographics
NPI:1619503349
Name:ALPINE DENITSTRY
Entity Type:Organization
Organization Name:ALPINE DENITSTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIFFIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-734-5200
Mailing Address - Street 1:PO BOX 11779
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-1779
Mailing Address - Country:US
Mailing Address - Phone:307-734-5200
Mailing Address - Fax:307-733-2922
Practice Address - Street 1:945 W BROADWAY AVE APT 201
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8217
Practice Address - Country:US
Practice Address - Phone:307-734-5200
Practice Address - Fax:307-733-2922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-13
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1669683025OtherNPI TYPE 1