1336404763 NPI number — MODERN DENTAL PROFESSIONALS UTAH, PC

Table of content: (NPI 1336404763)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336404763 NPI number — MODERN DENTAL PROFESSIONALS UTAH, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MODERN DENTAL PROFESSIONALS UTAH, 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:
6
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:
1336404763
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8415 DATAPOINT DR STE 1020
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78229-3277
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-929-2814
Provider Business Mailing Address Fax Number:
210-615-3626

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1140 W RIVERDALE RD
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
OGDEN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84405-3787
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-917-1502
Provider Business Practice Location Address Fax Number:
801-436-3222
Provider Enumeration Date:
07/11/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MARTINEZ
Authorized Official First Name:
LILIANA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING DIRECTOR
Authorized Official Telephone Number:
949-308-9792

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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