1720466303 NPI number — IVORY RIDGE PEDIATRIC DENTISTRY

Table of content: MARY ANN WORK DMD (NPI 1992761696)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720466303 NPI number — IVORY RIDGE PEDIATRIC DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IVORY RIDGE 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:
1720466303
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3401 NORTH CENTER STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEHI
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84043-0000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3401 N CENTER STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEHI
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84043-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-918-4135
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/14/2015

Additional Information

Authorized Official

Authorized Official Last Name:
NICOL
Authorized Official First Name:
MARCI
Authorized Official Middle Name:
Authorized Official Title or Position:
VP OF OPERATIONS
Authorized Official Telephone Number:
801-918-4135

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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