Provider Demographics
NPI:1003028325
Name:PEDIATRIC DENTISTRY, P.C.
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:S.
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:HIBBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-774-0770
Mailing Address - Street 1:2112 N HILL FIELD RD STE 1
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-4023
Mailing Address - Country:US
Mailing Address - Phone:801-774-0770
Mailing Address - Fax:
Practice Address - Street 1:2112 N HILL FIELD RD STE 1
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-4023
Practice Address - Country:US
Practice Address - Phone:801-774-0770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1455351223G0001X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529130165036Medicaid