Provider Demographics
NPI:1033532015
Name:FASHION PLACE DENTAL
Entity Type:Organization
Organization Name:FASHION PLACE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-262-7770
Mailing Address - Street 1:6095 S FASHION BLVD STE 290
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-7391
Mailing Address - Country:US
Mailing Address - Phone:801-262-7770
Mailing Address - Fax:801-262-2983
Practice Address - Street 1:6095 S FASHION BLVD STE 290
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7391
Practice Address - Country:US
Practice Address - Phone:801-262-7770
Practice Address - Fax:801-262-2983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-28
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT142863122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty