1154637825 NPI number — GRANGER PEDIATRIC DENTISTRY

Table of content: (NPI 1154637825)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154637825 NPI number — GRANGER PEDIATRIC DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRANGER PEDIATRIC 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:
Provider Other Organization Name Type Code:
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:
1154637825
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
GRANGER PEDIATRIC DENTISTRY
Provider Second Line Business Mailing Address:
P.O. BOX 18430
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84118-0430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-969-8881
Provider Business Mailing Address Fax Number:
801-969-8889

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
GRANGER PEDIATRIC DENTISTRY
Provider Second Line Business Practice Location Address:
3535 S MARKET STREET SUITE #145
Provider Business Practice Location Address City Name:
WEST VALLEY CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84119-3637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-969-8881
Provider Business Practice Location Address Fax Number:
801-969-8889
Provider Enumeration Date:
08/19/2010

Additional Information

Authorized Official

Authorized Official Last Name:
PETERSEN
Authorized Official First Name:
HANS
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER/DENTIST
Authorized Official Telephone Number:
801-969-8881

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  360305-9923 , 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)

  • Identifier: 526155793003 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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