Provider Demographics
NPI:1003206350
Name:BLUE MOUNTAIN FAMILY DENTAL
Entity Type:Organization
Organization Name:BLUE MOUNTAIN FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:HILMO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-356-7329
Mailing Address - Street 1:1675 N 200 W #8A
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-356-7329
Mailing Address - Fax:
Practice Address - Street 1:1675 N 200 W #8A
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604
Practice Address - Country:US
Practice Address - Phone:801-356-7329
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT73696451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT050828Medicaid