1851538862 NPI number — SALT LAKE DONATED DENTAL SERVICES

Table of content: (NPI 1851538862)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851538862 NPI number — SALT LAKE DONATED DENTAL SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SALT LAKE DONATED DENTAL SERVICES
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:
1851538862
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/16/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1383 S 900 W
Provider Second Line Business Mailing Address:
SUITE 128
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84104-1603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-983-0350
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1383 S 900 W
Provider Second Line Business Practice Location Address:
SUITE 128
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84104-1603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-983-0350
Provider Business Practice Location Address Fax Number:
801-983-0353
Provider Enumeration Date:
01/13/2009

Additional Information

Authorized Official

Authorized Official Last Name:
JENSEN
Authorized Official First Name:
STEPHANIE
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
801-983-0351

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 870422710002 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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