Provider Demographics
NPI:1003138843
Name:CHILDREN'S CROSSING PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:CHILDREN'S CROSSING PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:K
Authorized Official - Last Name:RUPP
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:801-635-4143
Mailing Address - Street 1:1528 N COMMERCE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:UT
Mailing Address - Zip Code:84045-4032
Mailing Address - Country:US
Mailing Address - Phone:801-766-4900
Mailing Address - Fax:
Practice Address - Street 1:1528 N COMMERCE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:UT
Practice Address - Zip Code:84045-4032
Practice Address - Country:US
Practice Address - Phone:801-766-4900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-22
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT53520621223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty