1477649697 NPI number — WASATCH FAMILY DENTISTRY

Table of content: (NPI 1477649697)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477649697 NPI number — WASATCH FAMILY DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WASATCH FAMILY DENTISTRY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BACK OF THE WASATCH FAMILY & COSMETIC DENTISTRY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477649697
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
380 E 1500 S
Provider Second Line Business Mailing Address:
#203
Provider Business Mailing Address City Name:
HEBER CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-654-4500
Provider Business Mailing Address Fax Number:
435-654-3728

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
380 E 1500 S
Provider Second Line Business Practice Location Address:
#203
Provider Business Practice Location Address City Name:
HEBER CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-654-4500
Provider Business Practice Location Address Fax Number:
435-654-3728
Provider Enumeration Date:
10/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LOBROT
Authorized Official First Name:
REED
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRES
Authorized Official Telephone Number:
435-654-4500

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  373732-9922 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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