Provider Demographics
NPI:1023186111
Name:RAYMOND SCOTT HLAVATY
Entity Type:Organization
Organization Name:RAYMOND SCOTT HLAVATY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:HLAVATY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD MS
Authorized Official - Phone:435-753-2828
Mailing Address - Street 1:150 E 200 NO
Mailing Address - Street 2:STE A
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321
Mailing Address - Country:US
Mailing Address - Phone:435-753-2828
Mailing Address - Fax:435-753-3628
Practice Address - Street 1:150 E 200 NO
Practice Address - Street 2:STE A
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321
Practice Address - Country:US
Practice Address - Phone:435-753-2828
Practice Address - Fax:435-753-3628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9326045799211223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528170323003Medicaid