Provider Demographics
NPI:1053648881
Name:MOUNT OGDEN DENTAL PC
Entity Type:Organization
Organization Name:MOUNT OGDEN DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:MR
Authorized Official - First Name:DERALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:GEDDES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-394-5554
Mailing Address - Street 1:1220 33RD STREET
Mailing Address - Street 2:SUITE D
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403
Mailing Address - Country:US
Mailing Address - Phone:801-394-5554
Mailing Address - Fax:801-394-2893
Practice Address - Street 1:12320 33RD STREET
Practice Address - Street 2:SUITE D
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403
Practice Address - Country:US
Practice Address - Phone:801-394-5554
Practice Address - Fax:801-394-2893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-16
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1444371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty