Provider Demographics
NPI:1093018111
Name:THE AVENUES FAMILY DENTISTRY
Entity Type:Organization
Organization Name:THE AVENUES FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:435-760-0189
Mailing Address - Street 1:215 S 1000 E STE A
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2486
Mailing Address - Country:US
Mailing Address - Phone:801-328-4173
Mailing Address - Fax:801-322-3995
Practice Address - Street 1:215 S 1000 E STE A
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2486
Practice Address - Country:US
Practice Address - Phone:801-328-4173
Practice Address - Fax:801-322-3995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-11
Last Update Date:2010-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT78288371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty