1013358449 NPI number — STANSBURY DENTAL AND IMPLANT CENTER PDC PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013358449 NPI number — STANSBURY DENTAL AND IMPLANT CENTER PDC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STANSBURY DENTAL AND IMPLANT CENTER PDC PLLC
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:
STANSBURY DENTAL AND IMPLANT CENTER
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:
1013358449
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 970596
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OREM
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84097-0309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-305-3460
Provider Business Mailing Address Fax Number:
801-335-6551

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
263 COUNTRY CLUB DR.
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
STANSBURY PARK
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84074-9600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-882-2850
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/15/2013

Additional Information

Authorized Official

Authorized Official Last Name:
WARNER
Authorized Official First Name:
JACOB
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
801-691-1701

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  341237 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223P0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223X0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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