1790793776 NPI number — ADVENTURE DENTAL

Table of content: (NPI 1790793776)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790793776 NPI number — ADVENTURE DENTAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVENTURE DENTAL
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:
HIDDEN VALLEY PEDIATRIC DENTAL
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:
1790793776
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 830
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DRAPER
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-495-1610
Provider Business Mailing Address Fax Number:
801-495-1631

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
114 E 12450 S
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
DRAPER
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-495-1610
Provider Business Practice Location Address Fax Number:
801-495-1631
Provider Enumeration Date:
08/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HUFFMAN
Authorized Official First Name:
ANNIE
Authorized Official Middle Name:
C
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
801-495-1610

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  342300 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X , with the licence number: 5832460 , 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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