Provider Demographics
NPI:1063032225
Name:HAVEN DENTAL LLC
Entity Type:Organization
Organization Name:HAVEN DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAVEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-786-0500
Mailing Address - Street 1:2797 N HIGHWAY 89 STE 300
Mailing Address - Street 2:
Mailing Address - City:PLEASANT VIEW
Mailing Address - State:UT
Mailing Address - Zip Code:84404-1232
Mailing Address - Country:US
Mailing Address - Phone:801-786-0500
Mailing Address - Fax:801-786-0520
Practice Address - Street 1:2685 N 1000 W
Practice Address - Street 2:
Practice Address - City:PLEASANT VIEW
Practice Address - State:UT
Practice Address - Zip Code:84414-2660
Practice Address - Country:US
Practice Address - Phone:435-310-4562
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-17
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528-391-112-007Medicaid