1740687706 NPI number — MODERN DENTAL PROFESSIONALS - UTAH, PC

Table of content: MS. KELSEY IRIS LARAMEE BCBA (NPI 1326547738)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740687706 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:
1740687706
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:
476 N 900 W STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AMERICAN FORK
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84003-5200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-756-5522
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
476 N 900 W STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AMERICAN FORK
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84003-5200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-756-5522
Provider Business Practice Location Address Fax Number:
801-758-8499
Provider Enumeration Date:
11/19/2014

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: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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