1255776431 NPI number — BONNEVILLE PREVENTIVE DENTISTRY PLLC

Table of content: (NPI 1255776431)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255776431 NPI number — BONNEVILLE PREVENTIVE DENTISTRY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BONNEVILLE PREVENTIVE DENTISTRY 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:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
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Provider Other Name Prefix Text:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1255776431
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3860 JACKSON AVE
Provider Second Line Business Mailing Address:
SUITE 6
Provider Business Mailing Address City Name:
OGDEN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84403-1956
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-627-0420
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3860 JACKSON AVE
Provider Second Line Business Practice Location Address:
SUITE 6
Provider Business Practice Location Address City Name:
OGDEN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84403-1956
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-627-0420
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/01/2013

Additional Information

Authorized Official

Authorized Official Last Name:
WOLPERT
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
801-627-0420

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  8289908 , 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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