1316962079 NPI number — COPPER CREEK DENTAL, PC

Table of content: (NPI 1316962079)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316962079 NPI number — COPPER CREEK DENTAL, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COPPER CREEK DENTAL, PC
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:
1316962079
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3078 W 7800 S
Provider Second Line Business Mailing Address:
STE 7-B
Provider Business Mailing Address City Name:
WEST JORDAN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84088-3707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-280-1911
Provider Business Mailing Address Fax Number:
801-255-2394

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3078 W 7800 S
Provider Second Line Business Practice Location Address:
STE 7-B
Provider Business Practice Location Address City Name:
WEST JORDAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84088-3707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-280-1911
Provider Business Practice Location Address Fax Number:
801-255-2394
Provider Enumeration Date:
07/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STALEY
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
801-280-1911

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  373483-9922 , 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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