Provider Demographics
NPI:1871253906
Name:LIFT DENTAL PLLC
Entity Type:Organization
Organization Name:LIFT DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TREY
Authorized Official - Middle Name:JACKSON
Authorized Official - Last Name:THYGERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-485-8888
Mailing Address - Street 1:920 S HOVER ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-7900
Mailing Address - Country:US
Mailing Address - Phone:303-485-8888
Mailing Address - Fax:
Practice Address - Street 1:920 S HOVER ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-7900
Practice Address - Country:US
Practice Address - Phone:303-485-8888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-30
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1730755430Medicaid