Provider Demographics
NPI:1083921704
Name:MOUNTAIN VIEW PEDIATRIC DENTISTRY OF LAYTON
Entity Type:Organization
Organization Name:MOUNTAIN VIEW PEDIATRIC DENTISTRY OF LAYTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:PACKHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-779-2900
Mailing Address - Street 1:195 E GENTILE ST
Mailing Address - Street 2:SUITE #11
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-3754
Mailing Address - Country:US
Mailing Address - Phone:801-779-2900
Mailing Address - Fax:
Practice Address - Street 1:195 E GENTILE ST
Practice Address - Street 2:SUITE #11
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-3754
Practice Address - Country:US
Practice Address - Phone:801-779-2900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-01
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6362621-9922261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental