1700821089 NPI number — MACKAY DENTAL AND ASSOCIATES

Table of content: (NPI 1700821089)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700821089 NPI number — MACKAY DENTAL AND ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MACKAY DENTAL AND ASSOCIATES
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:
1700821089
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:
3550 S 4800 W
Provider Second Line Business Mailing Address:
SUITE J
Provider Business Mailing Address City Name:
WEST VALLEY CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84120-2966
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-969-3025
Provider Business Mailing Address Fax Number:
801-969-6115

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3550 S 4800 W
Provider Second Line Business Practice Location Address:
SUITE J
Provider Business Practice Location Address City Name:
WEST VALLEY CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84120-2966
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-969-3025
Provider Business Practice Location Address Fax Number:
801-969-6115
Provider Enumeration Date:
06/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MACKAY
Authorized Official First Name:
LYNDON
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
801-969-3025

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  5331693 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 5923241 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 134443 , 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)

  • Identifier: 529557774001 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 83693 . This is a "PEHP DR DEMILLE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 1990 . This is a "PEHP DR LYNDON MACKAY" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 529271638001 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 529588149009 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 73439 . This is a "PEHP DR DAVID MACKAY" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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