Provider Demographics
NPI:1093138448
Name:SIMPLY DENTAL OF SOUTH JORDAN, LLC
Entity Type:Organization
Organization Name:SIMPLY DENTAL OF SOUTH JORDAN, LLC
Other - Org Name:SOUTH JORDAN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/BUSINESS DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:H
Authorized Official - Last Name:WEBB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-915-5947
Mailing Address - Street 1:1268 W SOUTH JORDAN PKWY
Mailing Address - Street 2:SUITE 302
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-4652
Mailing Address - Country:US
Mailing Address - Phone:801-253-3900
Mailing Address - Fax:801-253-3342
Practice Address - Street 1:1268 W SOUTH JORDAN PKWY
Practice Address - Street 2:SUITE 302
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-4652
Practice Address - Country:US
Practice Address - Phone:801-253-3900
Practice Address - Fax:801-253-3342
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SIMPLY DENTAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1391251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty